Journal of General Internal Medicine

, Volume 27, Issue 12, pp 1649–1656 | Cite as

“Did I Do as Best as the System Would Let Me?” Healthcare Professional Views on Hospital to Home Care Transitions

  • Melinda M. Davis
  • Meg Devoe
  • Devan Kansagara
  • Christina Nicolaidis
  • Honora Englander
Original Research



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.


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.


transition and discharge planning continuity of care communication quality improvement 




We would like to thank the providers and administrative staff who participated in this research and who continue to support implementation of the Care Transitions Innovation (C-TraIn). We are also grateful to Sonya Howk, MPA:HA and Dora Raymaker, MS for their assistance with data collection.


Funding for this project is provided by Oregon Health & Science University (OHSU), Portland, OR and by a Clinical and Translational Science Award to OHSU (National Institute of Health/National Center for Research Resources grant No. 1 UL1 RR024140 01).

Prior Presentations

Presented in part at the 34th annual meeting of the Society of General Internal Medicine, Phoenix, Arizona, May 4–7, 2011 and the Academy for Healthcare Improvement, Arlington, VA, May 7–8, 2012.

Conflict of Interest

The authors declare that they do not have a conflict of interest.


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Copyright information

© Society of General Internal Medicine 2012

Authors and Affiliations

  • Melinda M. Davis
    • 1
    • 2
  • Meg Devoe
    • 3
    • 4
  • Devan Kansagara
    • 3
    • 5
  • Christina Nicolaidis
    • 3
    • 6
  • Honora Englander
    • 3
    • 4
  1. 1.Oregon Rural Practice-based Research NetworkOregon Health & Science UniversityPortlandUSA
  2. 2.Department of Family MedicineOregon Health & Science UniversityPortlandUSA
  3. 3.Department of MedicineOregon Health & Science UniversityPortlandUSA
  4. 4.Central City ConcernPortlandUSA
  5. 5.Department of MedicineVeterans Affairs Medical CenterPortlandUSA
  6. 6.Department of Public Health & Preventive MedicineOregon Health & Science UniversityPortlandUSA

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