• Suzanne E Mitchell, Vivian Laurens, Gabriela M Weigel, Karen B Hirschman, Allison M Scott, Huong Q Nguyen, Jessica Martin Howard, Lance Laird, Carol Levine, Terry C Davis, Brianna Gass, Elizabeth Shaid, Jing Li, Mark V Williams, and Brian W Jack.
• Department of Family Medicine, Boston Medical Center/Boston University School of Medicine, Boston, Massachusetts (Mitchell, Laurens, Weigel, Howard, Jack); School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania (Hirschman, Shaid); Department of Communication, University of Kentucky, Lexington, Kentucky (Scott); Department of Research and Evaluation, Kaiser Permanente Southern California, Los Angeles, California (Nguyen); Medical Anthropology, Boston University School of Medicine, Boston, Massachusetts (Laird); Families and Health Care Project, United Hospital Fund, New York, New York (Levine); Department of Medicine and Pediatrics, Louisiana State University Health Sciences, New Orleans, Louisiana (Davis); Telligen, Quality Improvement, Des Moines, Iowa (Gass); Center for Health Services Research, University of Kentucky, Lexington, Kentucky (Li, Williams) suzanne.mitchell@bmc.org.
• Ann Fam Med. 2018 May 1; 16 (3): 225-231.

PurposeDespite concerted actions to streamline care transitions, the journey from hospital to home remains hazardous for patients and caregivers. Remarkably little is known about the patient and caregiver experience during care transitions, the services they need, or the outcomes they value. The aims of this study were to (1) describe patient and caregiver experiences during care transitions and (2) characterize patient and caregiver desired outcomes of care transitions and the health services associated with them.MethodsWe interviewed 138 patients and 110 family caregivers recruited from 6 health networks across the United States. We conducted 34 homogenous focus groups (103 patients, 65 caregivers) and 80 key informant interviews (35 patients, 45 caregivers). Audio recordings were transcribed and analyzed using principles of grounded theory to identify themes and the relationship between them.ResultsPatients and caregivers identified 3 desired outcomes of care transition services: (1) to feel cared for and cared about by medical providers, (2) to have unambiguous accountability from the health care system, and (3) to feel prepared and capable of implementing care plans. Five care transition services or provider behaviors were linked to achieving these outcomes: (1) using empathic language and gestures, (2) anticipating the patient's needs to support self-care at home, (3) collaborative discharge planning, (4) providing actionable information, and (5) providing uninterrupted care with minimal handoffs.ConclusionsClear accountability, care continuity, and caring attitudes across the care continuum are important outcomes for patients and caregivers. When these outcomes are achieved, care is perceived as excellent and trustworthy. Otherwise, the care transition is experienced as transactional and unsafe, and leaves patients and caregivers feeling abandoned by the health care system.© 2018 Annals of Family Medicine, Inc.

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