Post-hospitalization transition to home: Patient perspectives of a personalized approach

Abstract

Objective: Successful transition from hospital to home for persons having multiple chronic illnesses is vital for improved health and reduction of hospital readmissions. This qualitative study was undertaken to explore patients’ experiences with tailored care transition interventions in order to improve future interventions in a planned larger study.

Methods: Eighteen patients were interviewed either individually or in focus groups. Patients had previously completed a larger study that evaluated the impact of post-hospital discharge care transitions interventions, which were tailored to cognitive level and patient activation status. Data were analyzed using qualitative, thematic analysis techniques.

Results: The overarching theme identified as a result of the qualitative interviews was: Tailoring Interventions to Address the Complexity of Multiple Chronic Illnesses. It included Checking in or checking out: Patient activation and self-management of chronic illness; Increasing complexity: Management of medications for chronic illness; and Paving a path through complexity with caring. These themes were found in all participants, across all groups of the interventions.

Conclusions: Tailored interventions, which included individual assessment of needs and development and implementation of a tailored self-management plan, were viewed as effective by patients for self-management of chronic illness, particularly medication reconciliation and weekly goal setting.