“Did I Do as Best as the System Would Let Me?” Healthcare Professional Views on Hospital to Home Care Transitions
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.Get Access
Patients are vulnerable to poor quality, fragmented care as they transition from hospital to home. Few studies examine the discharge process from the perspectives of multiple healthcare professionals.
To understand care transitions from the perspective of diverse healthcare professionals, and identify recommendations for process improvement.
Cross sectional qualitative study.
PARTICIPANTS AND SETTING
Clinicians, care teams, and administrators from the inpatient general medicine services at one urban, academic hospital; two outpatient primary care clinics; and one Medicaid managed care plan.
We conducted 13 focus groups and two in-depth interviews with participants prior to initiating a hospital-funded, multi-component transitional care intervention for uninsured and low-income publicly insured patients, the Care Transitions Innovation (C-TraIn). We used thematic analysis to identify emergent themes and a cross-case comparative analysis to describe variation by participant role and setting.
Poor transitional care reflected healthcare system fragmentation, limiting the ability of healthcare professionals to provide optimal patient care. Lack of standardized processes, poor multidisciplinary communication within the hospital, and fragmented communication across settings led to chaotic, unsystematic transitions, poor patient outcomes, and feelings of futility and dissatisfaction among providers. Patients with complex psychosocial needs were especially vulnerable during care transitions. Recommended changes to improve transitional care included improving hospital multidisciplinary hospital rounds, clarifying accountability as patients move across settings, standardizing discharge processes, and providing additional medical staff training.
Hospital to home care transitions are critical junctures that can impact health outcomes, experience of care, and costs. Transitional care quality improvement initiatives must address system fragmentation, reduce communication barriers within and between settings, and ensure adequate professional training.
- Forster, AJ, Murff, HJ, Peterson, JF, Gandhi, TK, Bates, DW (2003) The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 138: pp. 161-167
- Forster, AJ, Clark, HD, Menard, A (2004) Adverse events among medical patients after discharge from hospital. Can Med Assoc J 170: pp. 345-349
- Kripalani, S, LeFevre, F, Phillips, CO, Williams, MV, Basaviah, P, Baker, DW (2007) Deficits in communication and information transfer between hospital-based and primary care physicians. JAMA 297: pp. 831-841 CrossRef
- Moore, C, Wisnivesky, J, Williams, S, McGinn, T (2003) Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med 18: pp. 646-651 CrossRef
- Jencks, SF, Williams, MV, Coleman, EA (2009) Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 360: pp. 1418-1428 CrossRef
- Coleman, EA, Mahoney, E, Parry, C (2005) Assessing the quality of preparation for posthospital care from the patient’s perspective: the care transitions measure. Med Care 43: pp. 246-255 CrossRef
- Kuo, Y-F, Sharma, G, Freeman, JL, Goodwin, JS (2009) Growth in the care of older patients by hospitalists in the United States. N Engl J Med 360: pp. 1102-1112 CrossRef
- Berwick, DM, Nolan, TW, Whittington, J (2008) The triple aim: care, health, and cost. Health Aff 27: pp. 759-769 CrossRef
- Naylor, MD, Brooten, DA, Campbell, RL, Maislin, G, McCauley, KM, Schwartz, JS (2004) Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc 52: pp. 675-684 CrossRef
- Coleman, EA, Parry, C, Chalmers, S, Min, SJ (2006) The care transitions intervention: results of a randomized controlled trial. Arch Intern Med 166: pp. 1822-1828 CrossRef
- Society, of Hospital Medicine. Project BOOST: Better Outcomes for Older adults through Safe Transitions. Society of Hospital Medicine, Philadelphia, PA. 2012. Available at: www.hospitalmedicine.org/boost. Accessed June 22 2012.
- Jack, BW, Chetty, VK, Anthony, D (2009) A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med 150: pp. 178-187
- Raven, MC, Billings, JC, Goldfrank, LR, Manheimer, ED, Gourevitch, MN (2009) Medicaid patients at high risk for frequent hospital admission: real-time identification and remediable risks. J Urban Health 86: pp. 230-241 CrossRef
- Compilation of Patient Protection and Affordable Care Act: as Amended Through 1 November 2010, Including Patient Protection and Affordable Care Act health-related portions of the Health Care and Education Reconciliation Act of 2010. U.S. Government Printing Office, Washington
- Minott, J (2008) Reducing Hospital Readmissions. Academy Health, Washington
- Englander H, Kansagara D. Planning and designing the Care Transitions Innovation (C-TraIn) for uninsured and Medicaid patients. J Hosp Med. 2012. doi:10.1002/jhm.1926.
- Administrative Data 2009, 2010. Oregon Health & Science University, Portland
- Cohen, DJ, Crabtree, BF (2008) Evaluative criteria for qualitative research in health care: controversies and recommendations. Ann Fam Med 6: pp. 331-339 CrossRef
- Kuzel, A Sampling in qualitative inquiry. In: Crabtree, BF, Miller, WL eds. (1999) Doing Qualitative Research. Sage Publications, Thousand Oaks, pp. 33-45
- Braun, V, Clarke, V (2006) Using thematic analysis in psychology. Qual Res Psychol 3: pp. 77-101 CrossRef
- Crabtree, BF, Miller, WL (1999) Doing Qualitative Research. Sage Publications, Inc, Thousand Oaks
- Khan, S, VanWynsberghe, R (2008) Cultivating the Under-Mined: Cross-Case Analysis as Knowledge Mobilization. Qualitative Social Research, Forum
- Coleman, EA (2003) Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc 51: pp. 549-555 CrossRef
- Committee, on Quality of Health Care in America, Institute, of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century: The National Academies Press; 2001.
- Rydeman, I, Törnkvist, L (2006) The patient’s vulnerability, dependence and exposed situation in the discharge process: experiences of district nurses, geriatric nurses and social workers. J Clin Nurs 15: pp. 1299-1307 CrossRef
- Eija, G, Marja-Leena, P (2005) Home care personnel’s perspectives on successful discharge of elderly clients from hospital to home setting. Scand J Caring Sci 19: pp. 288-295 CrossRef
- Foust JB, Vuckovic N, Henriquez E. Hospital to home health care transition: patient, caregiver, and clinician perspectives. West J Nurs Res. 2011.
- Hansen, LO, Young, RS, Hinami, K, Leung, A, Williams, MV (2011) Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med 155: pp. 520-528
- Rittenhouse, DR, Shortell, SM (2009) The patient-centered medical home. JAMA 301: pp. 2038-2040 CrossRef
- American, Academy of Family Physicians (AAFP), American, Academy of Pediatrics (AAP), American, College of Physicians (ACP), American, Osteopathic Association (AOA). Joint Principles of the Patient Centered Medical Home. 2007. Available at: http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home. Accessed June 22 2012.
- Bohmer, RMJ (2011) The four habits of high-value health care organizations. N Engl J Med 365: pp. 2045-2047 CrossRef
- Green, ML, Aagaard, EM, Caverzagie, KJ (2009) Charting the road to competence: developmental milestones for internal medicine residency training. J Grad Med Educ 1: pp. 5-20 CrossRef
- Aiyer, M, Kukreja, S, Ibrahim-Ali, W, Aldag, J (2009) Discharge planning curricula in internal medicine residency programs: a national survey. South Med J 102: pp. 795-799 CrossRef
- Alper, E, Rosenberg, EI, O’Brien, KE, Fischer, M, Durning, SJ (2009) Patient safety education at U.S. and Canadian medical schools: results from the 2006 Clerkship Directors in Internal Medicine survey. Acad Med 84: pp. 1672-1676 CrossRef
- Glasheen, JJ, Siegal, EM, Epstein, K, Kutner, J, Prochazka, AV (2008) Fulfilling the promise of hospital medicine: tailoring internal medicine training to address hospitalists’ needs. J Gen Intern Med 23: pp. 1110-1115 CrossRef
- Eskildsen M, Bonsall J, Miller A, Ohuabunwa U, Payne C, Rimler E. Handover and Care Transitions Training for Internal Medicine Residents. MedEdPORTAL. 2012. Available at: www.mededportal.org/publication/9101. Accessed June 22 2012.
- “Did I Do as Best as the System Would Let Me?” Healthcare Professional Views on Hospital to Home Care Transitions
Journal of General Internal Medicine
Volume 27, Issue 12 , pp 1649-1656
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- transition and discharge planning
- continuity of care
- quality improvement
- Industry Sectors
- Author Affiliations
- 1. Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR, USA
- 2. Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
- 3. Department of Medicine, Oregon Health & Science University, BTE 119, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
- 4. Central City Concern, Portland, OR, USA
- 5. Department of Medicine, Veterans Affairs Medical Center, Portland, OR, USA
- 6. Department of Public Health & Preventive Medicine, Oregon Health & Science University, Portland, OR, USA