Background: Patients, particularly the elderly and those who have chronic illnesses, often experience adverse events when transitioning from the hospital to home. An estimated 20% of all discharged patients suffer a preventable adverse event (e.g., reaction to medication) within three weeks of discharge and 20% of Medicare patients are readmitted to the hospital within 30 days of discharge. There is a need to develop effective approaches that meet the needs of patients during transitions of care. A large integrated healthcare network designed an Integrated Practice Unit (IPU) called Transition Services (TS) to enhance transitions of care for high risk and medically complex patients discharged from the hospital to home. During their hospitalization, TS patients enter a transition pathway that includes: a hospital follow-up evaluation within 72 hours of discharge, medication reconciliation by a pharmacist; consultation with a social worker, and weekly contact with providers and the care management team. TS patients have access to: 24/7 phone support, paramedicine visits, same day clinic scheduling, and coordinated transition to the next appropriate care location after 30 days from the time of discharge. Virtual technology is used to provide visits with patients in their home.
A multi-method qualitative research study was conducted to explore patient and clinic staff members’ perceptions of and experiences with the TS.

Methods: Four patients, 3 clinical staff members, and 1 non-clinical staff member were randomly selected to participate in key informant interviews. Ethnographic interviews were conducted with 2 patient navigators. All interviews were recorded and transcribed. A thematic analysis was conducted on the data using NVivo version 10.

Results: Patients reported that they enrolled in the TS to: avoid readmission, gain easy access to care, and obtain help managing their care after being discharged from the hospital. Patients associated their improved knowledge of their illness and their medication with the individualized attention provided by TS.
Clinical and non-clinical staff members perceived the TS as having a positive impact on the patients’: health literacy, engagement in their healthcare, and compliance with their care plans. Clinical and non-clinical staff members identified the following as the value of an integrated approach to transitions of care: patients gain easy access to care (through in-home visits and virtual technology); patients are more closely monitored when they may be vulnerable to adverse events; and patients have access to services that address their social and healthcare needs.

Conclusions: Patients and clinic staff members value patient-centered transitions of care approaches that: incorporate multi-disciplinary services to address potential barriers patients may face in accessing healthcare; meet patients’ social and healthcare needs; and incorporate technology (e.g., virtual visits) to expand access to care.