Despite efforts to understand how to reduce unnecessary healthcare utilization, reduce hospital readmissions and improve patient experience, patients and their family members still experience suboptimal transitions from hospital to home, according to a University of Kentucky-led study published today in the May/June edition of the Annals of Family Medicine. 

The article, “Experiencing Care Transitions from the Patient and Caregiver Perspective," provides results from focus groups and interviews conducted with 138 patients and 110 family caregivers from California, Colorado, Kentucky, Louisiana, New England, and Pennsylvania. Specifically, the researchers sought to identify the care transition outcomes that were most important to patients and their family caregivers, as well as the processes of care linked to these outcomes. 

In order to improve patient and family caregiver experiences and outcomes associated with care transitions, Project ACHIEVE, a five-year $15 million study funded by the Patient-Centered Outcomes Research Institute (PCORI) is comprehensively analyzing this process at more than 40 hospital sites nationwide.  

Led by Dr. Mark V. Williams, chief transformation and learning officer at UK HealthCare and director of the UK Center for Health Services Research, Project ACHIEVE is rigorously evaluating care transition strategies at participating hospital sites. In its first phase, Dr. Suzanne Mitchell at the Boston Medical Center, guided the research team in qualitative research focused on determining what experiences and outcomes matter most to patients and family caregivers.

Findings from this initial phase of the study reveal that accountability, continuity in care and caring attitudes from medical staff are important components of care transitions for patients and their family caregivers. When they experience these components, patients and caregivers perceive their care as excellent. However, when they are not experienced, patients and caregivers may feel unsafe and abandoned. 

Patient-Centered Outcomes Research Institute (PCORI) is an independent, nonprofit, nongovernmental organization with a mission of helping people make informed healthcare decisions and improving healthcare outcomes by producing high-integrity, evidence-based research findings guided by patients, caregivers, and the broader healthcare community.