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National Study: Patients and Family Caregivers Desire Clear Accountability, Care Continuity, and Caring Attitudes in Care Transitions

Despite the intensity of efforts launched in the past decade 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 (i.e., care transitions). Importantly, little is known about what patients and their family caregivers actually experience and desire from this process.

A team of researchers from across the U.S., including Penn Nursing’s Karen Hirschman, PhD, MSW, Research Associate Professor in the Department of Biobehavioral Health Sciences and the NewCourtland Term Chair in Health Transitions Research, are engaged in a national study – Project ACHIEVE – examining patient and family caregiver experiences and outcomes associated with care transitions.

Project ACHIEVE is comprehensively analyzing this process at more than 40 hospital sites nationwide. Results from focus groups and interviews conducted with 138 patients and 110 family caregivers from California, Colorado, Kentucky, Louisiana, Pennsylvania and sites across New England have been published in the May/June edition of the Annals of Family Medicine.

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:

What do patients and family caregivers want during transitions in care?

Patients and family caregivers identified three chief outcomes that they desired when undergoing a transition from hospital to home or other care setting:

  • To feel prepared and capable of implementing care plans;
  • Unambiguous accountability from the healthcare system; and
  • To feel cared for and cared about by medical providers.

How can providers help patients and their families achieve the outcomes they desire most?

Interviews revealed five care transition services or provider behaviors that were linked to achieving the outcomes that patients and their family caregivers identified as most important:

  • Providing actionable information;
  • Collaborative discharge planning;
  • Using empathic language and gestures;
  • Anticipating the patient’s needs to support self-care at home; and
  • Providing uninterrupted care with minimal handoffs.

Findings from this initial phase of the study reveal that accountability, continuity in care and caring attitudes from the 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.

The University of Pennsylvania research team for this national study includes Mary D. Naylor, PhD RN FAAN, the Director of the NewCourtland Center for Transitions and Health, Karen B. Hirschman, PhD MSW (co-coauthor of this paper), Kathleen McCauley, PhD RN FAAN FAHA, and Mark V. Pauly, PhD, from Wharton.

Funding for this on-going study is provided by the Patient-Centered Outcomes Research Institute. It 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.