Care Transitions From Patient and Caregiver Perspectives

In many ways, a successful care transition is in the eye of the beholder. Policy makers, researchers, and health system administrators have overwhelmingly focused on reduction of 30-day readmissions as the key criterion defining success in care transitions. While an important outcome, there has been plenty written in recent years raising concerns about putting all our eggs in the readmissions basket. The insightful study by Mitchell and colleagues will hopefully shift our focus to aspects of care transitions that truly matter to patients and their caregivers, and remind us that this is a care quality issue as much as it is an issue of cost and utilization.

Patients and caregivers want to feel cared about, to have accountability from the health care system, and to feel prepared at discharge. Mitchell, et al go on to define the 5 care transition services or behaviors linked with achievement of these outcomes. These findings (which partly echo foundational qualitative work by Eric Coleman and others) provide clear guidance for practicing clinicians, and suggest the need for a culture change in how we conceive of the continuum of hospital and outpatient care: too often we view the hospital stay as an end in and of itself, when it should perhaps be viewed as an opportunity to help the patient succeed in the outpatient setting.

We believe that graduate medical education is a largely untapped resource for sustainable culture change in care transitions. The findings in this paper point to several specific educational foci for students and residents. First, our trainees need to reconceptualize the social history as a critical piece of the clinical care database which includes such elements as instrumental social support, geography, and financial barriers to care. One cannot anticipate and support self-care without knowing that Aunt Diane manages all the medications, or that there is no one else at home to help with BID dressing changes. Second, we need to encourage trainees to ask questions and learn about aspects of medical care around the transition. We cannot adequately provide actionable information if we don't know this information, including things like which specific red flag symptoms to look out for in the individuals case, medication titration instructions in response to changes in self-monitoring data, and the expected time course for recovery from a given illness or procedure. We need to provide more models for inpatient team-based care similar to what is starting to happen in outpatient medical home settings. Trainees need to practice in collaborative care environments in order to contribute to collaborative discharge planning efforts. Finally, feedback on these efforts from patients and caregivers is necessary for improvement. By making efforts to see if a discharge was successful from a patient perspective, trainees avoid the cognitive trap of feedback sanction, where outcomes are unknown and therefore are assumed to be successful.

There is still much work left to be done in creating the system and training environments optimal for transitions of care. This paper suggests some ways forward, and we suggest looking to the newest generation of clinicians as a way to ensure these changes are here to stay.

Competing interests: None declared