• Melinda M Davis, Meg Devoe, Devan Kansagara, Christina Nicolaidis, and Honora Englander.
• Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR 97239, USA.
• J Gen Intern Med. 2012 Dec 1; 27 (12): 1649-56.

BackgroundPatients are vulnerable to poor quality, fragmented care as they transition from hospital to home. Few studies examine the discharge process from the perspectives of multiple healthcare professionals.ObjectiveTo understand care transitions from the perspective of diverse healthcare professionals, and identify recommendations for process improvement.DesignCross sectional qualitative study.Participants And SettingClinicians, care teams, and administrators from the inpatient general medicine services at one urban, academic hospital; two outpatient primary care clinics; and one Medicaid managed care plan.ApproachWe conducted 13 focus groups and two in-depth interviews with participants prior to initiating a hospital-funded, multi-component transitional care intervention for uninsured and low-income publicly insured patients, the Care Transitions Innovation (C-TraIn). We used thematic analysis to identify emergent themes and a cross-case comparative analysis to describe variation by participant role and setting.Key ResultsPoor transitional care reflected healthcare system fragmentation, limiting the ability of healthcare professionals to provide optimal patient care. Lack of standardized processes, poor multidisciplinary communication within the hospital, and fragmented communication across settings led to chaotic, unsystematic transitions, poor patient outcomes, and feelings of futility and dissatisfaction among providers. Patients with complex psychosocial needs were especially vulnerable during care transitions. Recommended changes to improve transitional care included improving hospital multidisciplinary hospital rounds, clarifying accountability as patients move across settings, standardizing discharge processes, and providing additional medical staff training.ConclusionsHospital to home care transitions are critical junctures that can impact health outcomes, experience of care, and costs. Transitional care quality improvement initiatives must address system fragmentation, reduce communication barriers within and between settings, and ensure adequate professional training.

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