Background: Care transitions programs are increasingly used to improve care and reduce re-admission of patients after hospitalization. To learn from the experience of patients who have participated in the Mayo Clinic Care Transitions (MCCT) program and to understand the patient experience, we sought perspectives of patients, caregivers, and providers who worked with participants of the MCCT program.
Methods: Investigators interviewed 17 patients and nine of their caregivers about their experience with the MCCT program. Eight health care providers described provider experiences with the MCCT program. Data from semistructured interviews were audio recorded, transcribed, and evaluated through content analysis. Inductive coding methods were used to elicit themes about patient experience with the MCCT program.
Results: Patients, caregivers, and providers emphasized that the MCCT program prevented hospitalizations and contributed to the health and quality of life of participants. All three stakeholder groups emphasized the value of the home visit and provision of the visit on a patient's "home turf" as central to the program. Patients appreciated speaking to a provider without the stress and exertion of a trip to the clinic. Caregivers appreciated improved communication provided in the home visit and felt that home visits gave them peace of mind. Patients, caregivers, and providers also identified the need for improved phone triage and communication.
Conclusion: Patients, caregivers, and providers acknowledged the care transitions problem and emphasized the benefits of seeing patients on their home turf rather than in an office visit. This qualitative study of patient, caregiver, and provider experiences further validates the importance of the MCCT program.
Keywords: geriatrics; home care; hospitalization; nurse practitioner; program evaluation.