Our study provides an analysis of patients’ and family members’ experiences and insights into improving care transitions. To our knowledge, this is the first study to describe patients’ and family members’ experiences and perceptions associated with interfacility care transitions involving acute care and CCC/rehab sites.
Study participants shared how gaps in information and not being involved in their care transition processes created key safety threats. In their view, patients and family members had to wait for information and explanations on their transfer and did not have a say as to where they would be transferred. For some study participants, this lack of engagement was experienced as not listening to their preferences and associated with discomfort around not knowing what was going to happen next. This finding is consistent with various studies that reported gaps in (1) information transfer among different levels of care, (2) planning and discharge instructions, and (3) fulfilling expectations of patients.17
Underpinning all of these gaps is ineffective communication between patients and health care professionals.
Our inferences warrant further attention, as there is a growing literature base on the risks associated with lack of respect for preferences and engagement of family or friends in their care. This work also includes studies linking patient-centered and quality improvement efforts in the hospital20
and explorations of patients’ and relatives’ perspectives on failures in health care.12
For example, one study demonstrated that the rate of adverse events among elderly patients discharged from the emergency department was directly linked to how well they understood their discharge instructions, including how to recognize warning signs.22
Patient and family concerns around timing of transfer and the transition to self-care also warrant further attention, especially among patients who may not be medically and/or cognitively prepared for such a transition. For some patients and family members, it was challenging to adjust from having more resources and health care professionals working with the patient in their recovery to being able to manage their own care at the complex care site. Interestingly, some patients linked the speed of the transfer process to the need to free up a bed in the acute care site. Although not the focus of the current study, as the demographic indicates, three patients were readmitted to the index hospital, one of which was for delirium, which suggests that in some cases the patient may indeed have been transferred too early.
In summary, the three key themes around what patients and family members view as key safety threats in their care transition experience are important to consider in their healing and recovery. Not surprisingly, to mitigate the aforementioned safety threats, study participants also offered ideas about how to improve care transitions to ensure they experience positive health outcomes and a smooth recovery from their injury. The need for a more coordinated approach that engages patients and family members in their care transitions is echoed in the call for patient-centered care and satisfaction,20
and the view of patients and families as safety experts.10
Collectively, this growing body of literature suggests that patient and family engagement in their care planning at different transition points, including listening to what they perceive as safety threats and providing opportunities for decision making in their care, will result in better care. Moreover, engaging patients and family members will also enable a greater understanding and assessment of what interventions may be effective, including the timing of when information should be exchanged around the patient’s recovery and care planning.24
Having a more coordinated approach to care transitions will ensure better care design and service planning for care transitions.1
Key to these efforts is having the responsibility of care coordination assigned to a professional or a team involved in the different levels of care.24
In the context of the current study, there was no point person who followed up or connected with the transferring patients once they were admitted to the CCC site. Study findings point to the need to develop and test out interventions aimed at a more coordinated approach that engages patients and family members in their care transitions.
There are promising signs of better care transition experiences. A transitional care model, a nurse-led, team-based care delivery innovation, has reported better clinical outcomes with reduced health care spending.2
A transitional care model approach includes comprehensive discharge planning with patient and caregiver goal setting and care planning in hospital with follow-up interventions.26
Follow-up interventions range from daily home videophone or telephone monitoring with self-care instruction and symptom management,29
assigning a nurse as the leader of care,28
or having a transitions coach27
to in-person home visits to discharged patients. This foundational work should guide efforts in future interventional research studies aimed at enhancing care transitions from the acute to CCC/rehab health care setting. Future work should also explore the use of technology (eg, telehealth methods and smart phone applications) as a means of obtaining information around patients’ health status, care, and discharge planning with patients and families during their care transitions. There are promising signs of using technology to increase the information available to patients and providers to improve care transitions, disease management, and safety.30
Study findings need to be interpreted with the following limitations. The first limitation is sample size and selection bias due to our study cohort representing a small sample of nonelective orthopedic patients transitioning between one acute care hospital and one CCC/rehab site. Thus, our study findings may not hold true for other orthopedic patients from other health care organizations or other patient populations. The second limitation is the biases associated with the self-reporting of safety threats and recommendations to improve care transitions by patients and family members. The third limitation is researcher bias, which is inherent in qualitative research. Steps to mitigate biases include recruiting a patient cohort that varies in age, medical history and reason for admission, using an open-ended interview guide to elicit patients’ and family members’ perspectives, and having three of the research team participating in the analysis. Despite these limitations, our study findings provide important insight into safety threats, challenges, and opportunities for improving interfacility transfers.