ArticleAnnals of family medicine2018
Care Transitions From Patient and Caregiver Perspectives.
Open access · diamondAbstract readMulticenter Study
In one paragraph
Article in Annals of family medicine, 2018. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 72 papers.
0numbers the graph read from it
0cells of the map it votes in
72citing papers in PubMed
36.3field-weighted citation impact, top 1% of its field
What it found
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The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
72 citing papers in PubMed, 224 citations in OpenAlex.
- Trial
- Facilitating the transition from hospital to home after hip fracture surgery: a qualitative study from the HIP HELPER trial.BMC geriatrics · 2024Trial
- Safe and effective person- and family-centered care practices during transitions from hospital to home-A web-based Delphi technique.PloS one · 2019Trial
- Adaptation Model for Patient and Caregiver Dyads in Hospital-to-Home Transition: Theory Development and Content Validation.Healthcare (Basel, Switzerland) · 2026Article
- Aligning Patient Discharge Curricula to Patient-Reported Outcomes in Sub Internship.Journal of general internal medicine · 2026Article
- Transitional care interventions and outcome measures in stroke rehabilitation: a scoping review.Disability and rehabilitation · 2026Review
- Virtual health coaching to improve self-care among informal caregivers of hospitalized older adults during a transition in care: Randomized controlled trial study protocol.Contemporary clinical trials · 2026Article
- Exploring Patient and Caregiver Work and Continuity of Care During Hospital-to-Home Transitions of Care in the Canadian Context.Health expectations : an international journal of public participation in health care and health policy · 2026Article
- Nurses' Role in Transitional Care During Intensive Care Unit Family Meetings for Patients With Prolonged Mechanical Ventilation.Journal of advanced nursing · 2026Article
- Culturally and Linguistically Diverse Informal Carer Experiences of Older Adult Care Transitions From Hospital to Home: A Scoping Review.Journal of advanced nursing · 2026Article
- Provision of medication supply at hospital discharge: A rapid scoping review of the "Meds-to-Beds" care model.American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists · 2026Article
- Participant feedback on a health care transition conference for youth with medical complexity.Health care transitions · 2026Article
- Care-Related Quality of Life of Caregivers for Patients With Low Vision and Blindness: A Cross-Sectional Study.Journal of ophthalmology · 2026Article
- "The first transition is from resident to patient": understanding the decisional needs of long-term care residents preparing for hospital transitions.The Gerontologist · 2025Article
- Leveraging the Transitional Care Model Intervention to Identify and Mitigate Adverse Social Determinants of Health.Journal of the American Medical Directors Association · 2025Article
- Caregiver Burden and 30-Day Emergency Department Revisits.JAMA network open · 2025Article
- Engineering Safe Care Journeys: Designing a Patient Safety Passport.Journal of patient safety · 2025Article
- Exploring success in sub-acute hospital-to-home transitions for palliative patients: a descriptive qualitative study.BMC palliative care · 2025Article
- Virtual Patient-PCP-Hospitalist Care Transition Meeting Before Hospital Discharge.JAMA network open · 2025Article
- Using Presence Circles to identify strategies to enhance nurse presence at discharge: a focus group study with nursing students.International journal of nursing studies advances · 2025Article
12 more citing papers are in PubMed but not listed here.
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
15 authors at 7 institutions in 1 country.
Suzanne E MitchellDepartment 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.
Vivian LaurensDepartment 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).
Gabriela M WeigelDepartment 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).
Karen B HirschmanDepartment 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).
Allison M ScottDepartment 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).
Huong Q NguyenDepartment 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).
Jessica Martin HowardDepartment 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).
Lance LairdDepartment 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).
Carol LevineDepartment 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).
Terry C DavisDepartment 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).
Brianna GassDepartment 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).
Elizabeth ShaidDepartment 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).
Jing LiDepartment 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).
Mark V WilliamsDepartment 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).
Brian W JackDepartment 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).
United Hospital Fund · USUniversity of Kentucky · USUniversity of Pennsylvania · USBoston University · USLouisiana State University Health Sciences Center New Orleans · USBoston Medical Center · USKaiser Permanente · US
Funding
Tracking & Evaluation CoreU54GM104940 · NIGMS · LSU PENNINGTON BIOMEDICAL RESEARCH CTR · PI Peter Todd Katzmarzyk · 2012 to 2026
$69.1MNIGMS NIH HHS U54 GM104940
Abstract
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.
Indexed as
Health Knowledge, Attitudes, PracticePatient DischargePatient TransferAdultAgedAged, 80 and overCaregiversFemaleFocus GroupsHumansMaleMiddle AgedQualitative ResearchUnited StatesYoung Adultcaregiverspatient readmissionpatient transfer
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