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5 Effective Care Transition Strategies Reduce Burden on Patients, Families and Caregivers


Discharge orders graphic.

By Mark V. Williams, MD and Jing Li, MD, DrPH, MS

Patients in the United States suffer harm too often as they move between sites of health care, and their family and caregivers experience significant burden. The usual approach to health care does not support continuity and coordination during “care transitions,” especially from hospital to home or post-acute care. Moreover, health care institutions often do not acknowledge and engage patients and family caregivers as true partners in the provision of care. 

Our Project ACHIEVE (Achieving Patient-Centered Care and Optimized Health In Care Transitions by Evaluating the Value of Evidence) aimed to address these gaps by evaluating hospitals’ implementation of transitional care (TC) strategies and identifying those that best address patient and caregiver goals.

In the study, “Effects of Different Transitional Care Strategies on Outcomes after Hospital Discharge—Trust Matters, Too,” from the January 2022 issue of The Joint Commission Journal on Quality and Patient Safety, we collected data on nearly 8,000 patients across 42 participating hospitals to evaluate the association of different combinations of TC strategies with patient-reported and post-discharge outcomes.

We identified five overlapping groups of TC strategies for analysis:

  1. Patient communication and care management
  2. Hospital-based trust, plain language and coordination
  3. Home-based trust, plain language and communication
  4. Patient/family caregiver assessment and information exchange among providers
  5. Assessment and teach back

The first three groups showed consistent trends in their association with a broad spectrum of patient outcomes, including health care utilization and patient-reported outcomes (PROs). These three groups were also characterized by an emphasis on patient- and caregiver-centered communication and coordination activities (e.g., Plain Language Communication, Promote Trust, Post-Discharge Care Consultation), as well as with better patient perception of health after hospitalization. 

However, hospital-based trust, plain language and coordination was the only group associated with lower 30-day rehospitalizations and emergency department visits within 7 days, among all the patients studied. This group included the following individual TC strategies:

  • Plain Language Communication at Hospital (e.g., explaining things in a way patients can understand)
  • Promote Trust in the Hospital (e.g., health care professionals care for patients as a person and patients trust their judgements about medical care)
  • Medication Reconciliation (e.g., designated person responsible for conducting medication reconciliation and clarifies medication list with outside sources when needed)
  • Post-Discharge Care Consultation (e.g., patient follow up via phone to reinforce education, and post-acute provider access to contact information for inpatient clinician)
  • Identify High-Risk Patients and Intervene (e.g., identify potential risks using medical, behavioral and social indicators, and initiate intervention(s) accordingly)
  • Transition Summary for Patients and Caregivers (e.g., document containing key information of hospital stay and follow-up to which patients and family caregivers can refer to and bring to outpatient services)

Engaging patients and their family caregivers in the transition process emerged from multiple sources in Project ACHIEVE as being key to safe transitions. In initial ACHIEVE research, patients and family caregivers clearly communicated what matters most to them during care transitions. 

Our research team’s article, “Experiencing Care Transitions from the Patient and Caregiver Perspective,” published in the Annals of Family Medicine, summarized focus groups and key informant interviews. Patients and family caregivers desired the following outcomes when experiencing a care transition: 

  1. feeling cared about by medical providers 
  2. sensing clear accountability from the health system regarding who is responsible for overseeing their care, and who to contact for help
  3. feeling prepared and capable to care for themselves, especially any potential complications

When these outcomes are achieved, care is perceived as excellent and providers as trustworthy. Otherwise, care transitions are seen as impersonal and unsafe. Patients and family caregivers also identified five medical provider behaviors linked to the three desired outcomes:

  1. using empathic language and gestures
  2. anticipating patient and family caregiver needs to support self-care at home
  3. collaborating on discharge planning
  4. providing actionable information 
  5. providing uninterrupted care with minimal handoffs

Our findings echo other’s research demonstrating positive health outcomes for patients who trust their health care providers. Amid health care systems becoming more and more complex, a focus on the relational aspects of health care provision may be warranted and truly value based. Fostering trust and plain language communication with patients is essential to improved transitional care when it’s done in concert with hospital-based approaches to coordination and facilitated collaborations across care settings.

Mark V. Williams, MD, is a Professor and Chief of the Division of Hospital Medicine at Washington University School of Medicine and Barnes-Jewish Hospitals in St. Louis, MO. Dr. Williams’ research interests focus on health literacy, performance improvement, care transitions, teamwork and implementation science.

Jing Li, MD, DrPH, MS, is an Associate Professor of Medicine at Washington University School of Medicine in St. Louis. Dr. Li’s research is motivated to improve the fragmented, inefficient and inconsistent health services delivery that yields suboptimal patient outcomes and quality of life.