@article {Mitchell225, author = {Suzanne E. Mitchell and Vivian Laurens and Gabriela M. Weigel and Karen B. Hirschman and Allison M. Scott and Huong Q. Nguyen and Jessica Martin Howard and Lance Laird and Carol Levine and Terry C. Davis and Brianna Gass and Elizabeth Shaid and Jing Li and Mark V. Williams and Brian W. Jack}, title = {Care Transitions From Patient and Caregiver Perspectives}, volume = {16}, number = {3}, pages = {225--231}, year = {2018}, doi = {10.1370/afm.2222}, publisher = {The Annals of Family Medicine}, abstract = {PURPOSE Despite concerted actions to streamline care transitions, the journey from hospital to home remains hazardous for patients and caregivers. Remarkably little is known about the patient and caregiver experience during care transitions, the services they need, or the outcomes they value. The aims of this study were to (1) describe patient and caregiver experiences during care transitions and (2) characterize patient and caregiver desired outcomes of care transitions and the health services associated with them.METHODS We interviewed 138 patients and 110 family caregivers recruited from 6 health networks across the United States. We conducted 34 homogenous focus groups (103 patients, 65 caregivers) and 80 key informant interviews (35 patients, 45 caregivers). Audio recordings were transcribed and analyzed using principles of grounded theory to identify themes and the relationship between them.RESULTS Patients and caregivers identified 3 desired outcomes of care transition services: (1) to feel cared for and cared about by medical providers, (2) to have unambiguous accountability from the health care system, and (3) to feel prepared and capable of implementing care plans. Five care transition services or provider behaviors were linked to achieving these outcomes: (1) using empathic language and gestures, (2) anticipating the patient{\textquoteright}s needs to support self-care at home, (3) collaborative discharge planning, (4) providing actionable information, and (5) providing uninterrupted care with minimal handoffs.CONCLUSIONS Clear accountability, care continuity, and caring attitudes across the care continuum are important outcomes for patients and caregivers. When these outcomes are achieved, care is perceived as excellent and trustworthy. Otherwise, the care transition is experienced as transactional and unsafe, and leaves patients and caregivers feeling abandoned by the health care system.}, issn = {1544-1709}, URL = {https://www.annfammed.org/content/16/3/225}, eprint = {https://www.annfammed.org/content/16/3/225.full.pdf}, journal = {The Annals of Family Medicine} }