Stakeholder engagement increases transparency, satisfaction, and civic action.

This study evaluates the effectiveness of a Stakeholder Engagement (SE) intervention in improving outcomes for communities affected by oil and gas extraction in Western Uganda. The study design is a randomized controlled trial where villages are randomly assigned to a treatment group (participating in SE) or a control group (not participating). Data are collected via household surveys at baseline and end line in 107 villages in the Albertine Graben. We find that SE improves transparency, civic activity, and satisfaction with issues that most concern the people under study. While satisfaction has improved, it is too early to ascertain whether these interventions improve long-term outcomes. These results are robust when controlling for spillover effects and other subregional fixed effects.

Patient, Caregiver, and Clinician Perspectives on Expectations for Home Healthcare after Discharge: A Qualitative Case Study.

BACKGROUND: Patients discharged from the hospital with skilled home healthcare (HHC) services have multiple comorbidities, high readmission rates, and multiple care needs. In prior work, HHC nurses described that patients often express expectations for services beyond the scope of skilled HHC. OBJECTIVE: The objective of this study is to evaluate and compare expectations for HHC from the patient, caregiver, and HHC perspectives after hospital discharge. DESIGN/PARTICIPANTS: This was a descriptive qualitative case study including HHC patients, caregivers, and clinicians. Patients were discharged from an academic medical center between July 2017 and February 2018. RESULTS: The sample (N = 27) included 11 HHC patients, eight caregivers, and eight HHC clinicians (five nurses and three physical therapists). Patient mean age was 66 years and the majority were female, white, and had Medicare. We observed main themes of clear and unclear expectations for HHC after discharge. Clear expectations occur when the patient and/or caregiver have expectations for HHC aligned with the services received. Unclear expectations occur when the patient and/or caregiver expectations are uncertain or misaligned with the services received. Patients and caregivers with clear expectations for HHC frequently described prior experiences with skilled HHC or work experience within the healthcare field. In most cases with unclear expectations, the patient and caregiver did not have prior experience with HHC. CONCLUSIONS: To improve HHC transitions, we recommend actively engaging both patients and caregivers in the hospital and HHC settings to provide education about HHC services, and assess and address additional care needs.

Quality of Hospital Communication and Patient Preparation for Home Health Care: Results From a Statewide Survey of Home Health Care Nurses and Staff.

OBJECTIVES: To evaluate the quality of communication between hospitals and home health care (HHC) clinicians and patient preparedness to receive HHC in a statewide sample of HHC nurses and staff. DESIGN: A web-based 48-question cross-sectional survey of HHC nurses and staff in Colorado to describe the quality of communication after hospital discharge and patient preparedness to receive HHC from the perspective of HHC nurses and staff. Questions were on a Likert scale, with optional free-text questions. SETTING AND PARTICIPANTS: Between January and June 2017, we sent a web-based survey to individuals from the 56 HHC agencies in the Home Care Association of Colorado that indicated willingness to participate. RESULTS: We received responses from 50 of 122 individuals (41% individual response rate) representing 14 of 56 HHC agencies (25% agency response rate). Half of the respondents were HHC nurses, the remainder were managers, administrators, or quality assurance clinicians. Among respondents, 60% (n = 30) reported receiving insufficient information to guide patient management in HHC and 44% (n = 22) reported encountering problems related to inadequate patient information. Additional tests recommended by hospital clinicians was the communication domain most frequently identified as insufficient (58%). More than half of respondents (52%) indicated that patient preparation to receive HHC was inadequate, with patient expectations frequently including extended-hours caregiving, housekeeping, and transportation, which are beyond the scope of HHC. Respondents with electronic health record (EHR) access for referring providers were less likely to encounter problems related to a lack of information (27% vs 57% without EHR access, P = .04). Respondents with EHR access were also more likely to have sufficient information about medications and contact isolation. CONCLUSIONS/IMPLICATIONS: Communication between hospitals and HHC is suboptimal, and patients are often not prepared to receive HHC. Providing EHR access for HHC clinicians is a promising solution to improve the quality of communication.

Improving the ED-to-Home Transition: The Community Paramedic-Delivered Care Transitions Intervention-Preliminary Findings.

OBJECTIVES: To describe a novel model of care that uses community-based paramedics to deliver a modified version of the evidence-based hospital-to-home Care Transitions Intervention (CTI) to a new context: the emergency department (ED)-to-home transition. DESIGN: Single-blind randomized controlled trial. SETTING: Three EDs in 2 cities. PARTICIPANTS: Through June 2017, 422 individuals discharged home from the EDs who provided consent and were randomized to receive the modified CTI. INTERVENTION: We modified the hospital-to-home CTI, applying it to the ED-to-home transition and delivering services through community paramedics, allowing the program to benefit from the unique attributes of paramedics to deliver care. MEASUREMENTS: Through surveys of participants, medical record review, and documentation of activities by CTI coaches, we characterize the participants and program, including feasibility and acceptability. RESULTS: Median age of participants was 70.7, 241 (57.1%) were female, and 385 (91.2%) were white. Coaches successfully completed 354 (83.9%) home visits and 92.7% of planned telephone follow-up for call 1, 90.9% for call 2, and 85.8% for call 3. We found high levels of acceptability among participants, with most participants (76.2%) and their caregivers (83.1%) reporting themselves likely or extremely likely to choose an ED featuring the CTI program in the future. Coaches reported delivering expected services during contact at least 88% of the time. CONCLUSION: Although final conclusions about program effectiveness must await the results of the randomized controlled trial, the findings reported here are promising and provide preliminary support for an ED-to-home CTI Program's ability to improve outcomes. The coaches' identity as community paramedics is particularly noteworthy, because this is a unique role for this provider type. J Am Geriatr Soc 66:2213-2220, 2018.

Age trends in 30 day hospital readmissions: US national retrospective analysis.

OBJECTIVE: To assess trends in and risk factors for readmission to hospital across the age continuum. DESIGN: Retrospective analysis. SETTING AND PARTICIPANTS: 31 729 762 index hospital admissions for all conditions in 2013 from the US Agency for Healthcare Research and Quality Nationwide Readmissions Database. MAIN OUTCOME MEASURE: 30 day, all cause, unplanned hospital readmissions. Odds of readmission were compared by patients' age in one year epochs with logistic regression, accounting for sex, payer, length of stay, discharge disposition, number of chronic conditions, reason for and severity of admission, and data clustering by hospital. The middle (45 years) of the age range (0-90+ years) was selected as the age reference group. RESULTS: The 30 day unplanned readmission rate following all US index admissions was 11.6% (n=3 678 018). Referenced by patients aged 45 years, the adjusted odds ratio for readmission increased between ages 16 and 20 years (from 0.70 (95% confidence interval 0.68 to 0.71) to 1.04 (1.02 to 1.06)), remained elevated between ages 21 and 44 years (range 1.02 (1.00 to 1.03) to 1.12 (1.10 to 1.14)), steadily decreased between ages 46 and 64 years (range 1.02 (1.00 to 1.04) to 0.91 (0.90 to 0.93)), and decreased abruptly at age 65 years (0.78 (0.77 to 0.79)), after which the odds remained relatively constant with advancing age. Across all ages, multiple chronic conditions were associated with the highest adjusted odds of readmission (for example, 3.67 (3.64 to 3.69) for six or more versus no chronic conditions). Among children, young adults, and middle aged adults, mental health was one of the most common reasons for index admissions that had high adjusted readmission rates (≥75th centile). CONCLUSIONS: The likelihood of readmission was elevated for children transitioning to adulthood, children and younger adults with mental health disorders, and patients of all ages with multiple chronic conditions. Further attention to the measurement and causes of readmission and opportunities for its reduction in these groups is warranted.

Qualitative Evaluation of the Coach Training within a Community Paramedicine Care Transitions Intervention.

OBJECTIVE: The Care Transitions Intervention (CTI) has potential to improve the emergency department (ED)-to-home transition for older adults. Community paramedics may function as the CTI coaches; however, this requires the appropriate knowledge, skills, and attitudes, which they do not receive in traditional emergency medical services (EMS) education. This study aimed to define community paramedics' perceptions regarding their training needs to serve as CTI coaches supporting the ED-to-home transition. METHODS: This study forms part of an ongoing randomized controlled trial evaluating a community paramedic-implemented CTI to enhance the ED-to-home transition. The community paramedics' training covered the following domains: the CTI program, geriatrics, effective coaching, ED discharge processes, and community paramedicine. Sixteen months after starting the study, we conducted audio-recorded semi-structured interviews with community paramedics at both study sites. After transcribing the interviews, team members independently coded the transcripts. Ensuing group analysis sessions led to the development of final codes and identifying common themes. Finally, we conducted member checking to confirm our interpretations of the interview data. RESULTS: We interviewed all 8 participating community paramedics. Participants consisted solely of non-Hispanic whites, included 5 women, and had a mean age of 43. Participants had extensive backgrounds in healthcare, primarily as EMS providers, but minimal experience with community paramedicine. All reported some prior geriatrics training. Four themes emerged from the interviews: (1) paramedics with positive attitudes and willingness to acquire the needed knowledge and skills will succeed as CTI coaches; (2) active rather than passive learning is preferred by paramedics; (3) the existing training could benefit from adjustments such as added content on mental health, dementia, and substance abuse issues, as well as content on coaching subjects with a range of illness severity; and (4) continuing education should address the paramedic coaches' evolving needs as they develop proficiency with the CTI. CONCLUSIONS: Paramedics as CTI coaches represent an untapped resource for supporting ED-to-home care transitions. Our results provide the necessary first step to make the community paramedic CTI coach more successful. These findings may apply to training for similar community paramedicine roles, but additional research must investigate this possibility.

Measuring care transitions in Sweden: validation of the care transitions measure.

OBJECTIVE: To translate and assess the validity and reliability of the original American Care Transitions Measure, both the 15-item and the shortened 3-item versions, in a sample of people in transition from hospital to home within Sweden. DESIGN: Translation of survey items, evaluation of psychometric properties. SETTING: Ten surgical and medical wards at five hospitals in Sweden. PARTICIPANTS: Patients discharged from surgical and medical wards. MAIN OUTCOME MEASURE: Psychometric properties of the Swedish versions of the 15-item (CTM-15) and the 3-item (CTM-3) Care Transition Measure. RESULTS: We compared the fit of nine models among a sample of 194 Swedish patients. Cronbach's alpha was 0.946 for CTM-15 and 0.74 for CTM-3. The model indices for CTM-15 and CTM-3 were strongly indicative of inferior goodness-of-fit between the hypothesized one-factor model and the sample data. A multidimensional three-factor model revealed a better fit compared with CTM-15 and CTM-3 one factor models. The one-factor solution, representing 4 items (CTM-4), showed an acceptable fit of the data, and was far superior to the one-factor CTM-15 and CTM-3 and the three-factor multidimensional models. The Cronbach's alpha for CTM-4 was 0.85. CONCLUSIONS: CTM-15 with multidimensional three-factor model was a better model than both CTM-15 and CTM-3 one-factor models. CTM-4 is a valid and reliable measure of care transfer among patients in medical and surgical wards in Sweden. It seems the Swedish CTM is best represented by the short Swedish version (CTM-4) unidimensional construct.

Influence of Nonindex Hospital Readmission on Length of Stay and Mortality.

IMPORTANCE: Hospitals and health care systems face increasing accountability for postdischarge outcomes of patients, but it is unclear how frequently hospital readmissions in particular occur at a different hospital than the index hospitalization and whether this is associated with worse outcomes. OBJECTIVE: Describe the prevalence of nonindex 30-day readmissions in a nationally representative sample of all payers and associations with outcomes. DESIGN: Secondary retrospective analysis of the 2013 Nationwide Readmissions Database. SETTING: Nonfederal hospitals from 21 states representing half of hospitalizations in the United States annually. PARTICIPANTS: Our overall sample included all adults discharged alive from an inpatient stay with 30 days of follow-up; we also created 3 additional cohorts: patients with Medicare as the payer (Medicare cohort), patients discharged to home health or skilled nursing facilities after discharge (postacute care cohort), and Medicare patients with any of the current Hospital Readmission Reduction Program's penalized conditions (readmission penalty cohort). EXPOSURE: Readmission within 30 days to "index" hospital (where index stay occurred) or "nonindex" hospital. MAIN OUTCOME(S) AND MEASURE(S): In-hospital mortality and length of stay during the readmission. RESULTS: The weighted overall sample included 22,884,505 hospital discharges from 2004 unique hospitals. The overall 30-day readmission rate was 11.9%, of these, 22.5% occurred at a nonindex hospital. Readmissions to nonindex facilities were associated with increased odds of in-hospital mortality (odds ratio, 1.21; 95% confidence interval, 1.17-1.25) and longer hospital length of stay (hazard ratio for hospital discharge, 0.87; 95% confidence interval, 0.86-0.88) in the overall sample and in the 3 cohorts. CONCLUSIONS AND RELEVANCE: Nonindex readmissions are common and associated with worse outcomes; the common findings across cohorts highlight the importance for hospitals and care systems participating in value-based payment models. Hospitals and care systems should invest in improved methods for real-time identification and intervention for these patients.

Use of post-acute care after hospital discharge in urban and rural hospitals.

OBJECTIVES: Geographic variation in the use of post-acute care (PAC - skilled nursing facility and home health care) after hospital discharge is substantial, but reasons for this remain largely unexplored. PAC use in urban hospitals compared to rural hospitals may be one key contributor. We aimed to describe PAC use, explore substitution of one type of PAC for another, and identify how PAC use varies by diagnosis in urban and rural settings. STUDY DESIGN: Secondary analysis of the 2012 National Inpatient Sample including adult discharges to PAC after a hospitalization. METHODS: We adjusted for differences in patient demographics, comorbidities, hospital care provided, and hospital information, comparing use of PAC in urban and rural settings in multivariable logistic regression. RESULTS: Rural patients discharged from rural hospitals constituted 188,137 (12.1%) of the 1.56 million discharges in the sample. Rural discharges received less home health care (0.85; 0.80-0.90) than urban discharges, resulting in less rural PAC use overall (0.95; 0.91-0.99). Rural discharges received more overall PAC for stroke (OR 1.11; 95% CI 1.03-1.19) and less PAC for sepsis (0.92; 0.86-0.98), hip fracture (0.82; 0.70-0.96), and elective joint arthroplasty, where rural discharges had 41% lower odds of receiving PAC (0.59; 0.49-0.71). CONCLUSIONS: The striking differences in receipt of post-acute care in urban and rural patients may constitute a disparity. Evaluation of costs and outcomes of PAC use in these settings is urgently needed as Medicare expands bundled payments for this care.

"Connecting the Dots": A Qualitative Study of Home Health Nurse Perspectives on Coordinating Care for Recently Discharged Patients.

BACKGROUND: In 2012, nearly one-third of adults 65 years or older with Medicare discharged to home after hospitalization were referred for home health care (HHC) services. Care coordination between the hospital and HHC is frequently inadequate and may contribute to medication errors and readmissions. Insights from HHC nurses could inform improvements to care coordination. OBJECTIVE: To describe HHC nurse perspectives about challenges and solutions to coordinating care for recently discharged patients. DESIGN/PARTICIPANTS: We conducted a descriptive qualitative study with six focus groups of HHC nurses and staff (n = 56) recruited from six agencies in Colorado. Focus groups were recorded, transcribed, and analyzed using a mixed deductive/inductive approach to theme analysis with a team-based iterative method. KEY RESULTS: HHC nurses described challenges and solutions within domains of Accountability, Communication, Assessing Needs & Goals, and Medication Management. One additional domain of Safety, for both patients and HHC nurses, emerged from the analysis. Within each domain, solutions for improving care coordination included the following: 1) Accountability-hospital physicians willing to manage HHC orders until primary care follow-up, potential legislation allowing physician assistants and nurse practitioners to write HHC orders; 2) Communication-enhanced access to hospital records and direct telephone lines for HHC; 3) Assessing Needs & Goals-liaisons from HHC agencies meeting with patients in hospital; 4) Medication Management-HHC coordinating directly with clinician or pharmacist to resolve discrepancies; and 5) Safety-HHC nurses contributing non-reimbursable services for patients, and ensuring that cognitive and behavioral health information is shared with HHC. CONCLUSIONS: In an era of shared accountability for patient outcomes across settings, solutions for improving care coordination with HHC are needed. Efforts to improve care coordination with HHC should focus on clearly defining accountability for orders, enhanced communication, improved alignment of expectations for HHC between clinicians and patients, a focus on reducing medication discrepancies, and prioritizing safety for both patients and HHC nurses.

Post-acute care reform: Implications and opportunities for hospitalists.

Nearly all practicing hospitalists have firsthand experience discharging patients to post-acute care (PAC), which is provided by inpatient rehabilitation facilities, skilled nursing facilities, or home healthcare providers. Many may not know that PAC is poised to undergo transformative change, spurred by recent legislation resulting in a range of reforms. These reforms have the potential to fundamentally reshape the relationship between hospitals and PAC providers. They have important implications for hospitalists and will open up opportunities for hospitalists to improve healthcare value. In this article, the authors explore the reasons for PAC reform and the scope of the reforms. Then they describe the implications for hospitalists and hospitalists' opportunities to Choose Wisely and improve healthcare value for the rapidly growing number of vulnerable older adults transitioning to PAC after hospital discharge.

Characteristics Associated with Home Health Care Referrals at Hospital Discharge: Results from the 2012 National Inpatient Sample.

OBJECTIVE: To assess patient- and hospital-level factors associated with home health care (HHC) referrals following nonelective U.S. patient hospitalizations in 2012. DATA SOURCE: The 2012 National Inpatient Sample (NIS). STUDY DESIGN: Retrospective, cross-sectional multivariable logistic regression modeling to assess patient- and hospital-level variables in patient discharges with versus without HHC referrals. DATA COLLECTION: Analysis included 1,109,905 discharges in patients ≥65 years with Medicare. PRINCIPAL FINDINGS: About 29.2 percent of discharges were referred to HHC, which were more likely with older age, female sex, urban location, low income, longer length of stay, higher severity of illness scores, diagnoses of heart failure or sepsis, and hospital location in New England (referent: Pacific). CONCLUSIONS: As health policy changes influence postacute HHC, defining specific diagnoses and regional patterns associated with HHC is a first step to optimize postacute HHC services.

Hospital to Post-Acute Care Facility Transfers: Identifying Targets for Information Exchange Quality Improvement.

INTRODUCTION: Information exchange is critical to high-quality care transitions from hospitals to post-acute care (PAC) facilities. We conducted a survey to evaluate the completeness and timeliness of information transfer and communication between a tertiary-care academic hospital and its related PAC facilities. METHODS: This was a cross-sectional Web-based 36-question survey of 110 PAC clinicians and staff representing 31 PAC facilities conducted between October and December 2013. RESULTS: We received responses from 71 of 110 individuals representing 29 of 31 facilities (65% and 94% response rates). We collapsed 4-point Likert responses into dichotomous variables to reflect completeness (sufficient vs insufficient) and timeliness (timely vs not timely) for information transfer and communication. Among respondents, 32% reported insufficient information about discharge medical conditions and management plan, and 83% reported at least occasionally encountering problems directly related to inadequate information from the hospital. Hospital clinician contact information was the most common insufficient domain. With respect to timeliness, 86% of respondents desired receipt of a discharge summary on or before the day of discharge, but only 58% reported receiving the summary within this time frame. Through free-text responses, several participants expressed the need for paper prescriptions for controlled pain medications to be sent with patients at the time of transfer. DISCUSSION: Staff and clinicians at PAC facilities perceive substantial deficits in content and timeliness of information exchange between the hospital and facilities. Such deficits are particularly relevant in the context of the increasing prevalence of bundled payments for care across settings as well as forthcoming readmissions penalties for PAC facilities. Targets identified for quality improvement include structuring discharge summary information to include information identified as deficient by respondents, completion of discharge summaries before discharge to PAC facilities, and provision of hard-copy opioid prescriptions at discharge.

Family caregivers as partners in care transitions: The caregiver advise record and enable act.

The objective of this Perspective was to provide guidance to hospitalists and hospital clinical leadership on how to implement the Caregiver Advise Record and Enable (CARE) Act, which has been passed into law in 30 US states and territories. Specifically, the objective is 3-fold: (1) increase awareness among hospitalists and encourage them to begin to prepare for implementation, (2) explore the impetus for this legislation, and (3) provide a list of suggested resources geared to both family caregivers and healthcare professionals that may be helpful in preparation for implementing the CARE Act. Journal of Hospital Medicine 2015;11:883-885. © 2015 Society of Hospital Medicine.

Hospital Readmission From Post-Acute Care Facilities: Risk Factors, Timing, and Outcomes.

OBJECTIVES: Hospital discharges to post-acute care (PAC) facilities have increased rapidly. This increase may lead to more hospital readmissions from PAC facilities, which are common and poorly understood. We sought to determine the risk factors and timing for hospital readmission from PAC facilities and evaluate the impact of readmission on patient outcomes. DESIGN: Retrospective analysis of Medicare Current Beneficiary Survey (MCBS) from 2003-2009. SETTING: The MCBS is a nationally representative survey of beneficiaries matched with claims data. PARTICIPANTS: Community-dwelling beneficiaries who were hospitalized and discharged to a PAC facility for rehabilitation. INTERVENTION/EXPOSURE: Potential readmission risk factors included patient demographics, health utilization, active medical conditions at time of PAC admission, and PAC characteristics. MEASUREMENTS: Hospital readmission during the PAC stay, return to community residence, and all-cause mortality. RESULTS: Of 3246 acute hospitalizations followed by PAC facility stays, 739 (22.8%) included at least 1 hospital readmission. The strongest risk factors for readmission included impaired functional status (HR 4.78, 95% CI 3.21-7.10), markers of increased acuity such as need for intravenous medications in PAC (1.63, 1.39-1.92), and for-profit PAC ownership (1.43, 1.21-1.69). Readmitted patients had a higher mortality rate at both 30 days (18.9% vs 8.6%, P < .001) and 100 days (39.9% vs 14.5%, P < .001) even after adjusting for age, comorbidities, and prior health care utilization (30 days: OR 2.01, 95% CI 1.60-2.54; 100 days: OR 3.79, 95% CI 3.13-4.59). CONCLUSIONS: Hospital readmission from PAC facilities is common and associated with a high mortality rate. Readmission risk factors may signify inadequate transitional care processes or a mismatch between patient needs and PAC resources.

The Family Caregiver Activation in Transitions (FCAT) Tool: A New Measure of Family Caregiver Self-Efficacy.

BACKGROUND: Family caregivers play an instrumental role in executing the care plan of patients during care transitions and yet may lack preparation and confidence to be effective. Yet there has been little attempt by health care professionals to identify and strengthen family caregivers' sense of preparation and confidence. The Family Caregiver Activation in Transitions™ (FCAT™) tool was developed to guide the care team in better understanding patient and family needs and deploying appropriate resources accordingly. METHODS: The development and psychometric testing of the FCAT tool was guided by a "partial credit" Rasch model. The validation was completed in three phases. In Phase 1, cognitive testing was conducted in convenience samples of family caregivers (N=54) participating in support groups in two geographic locations. In Phase 2, pilot testing was conducted (N=50) to determine item fit and item difficulty. In Phase 3, the tool's psychometric properties were examined in two waves of recruitment (N=187; N=247) from Web-based national samples. RESULTS: Participants recommended revising the script, reducing redundancy, and simplifying item structure and language. Analysis of item fit and difficulty guided subsequent item reduction. The estimated person-separation reliability was 0.84. CONCLUSIONS: The FCAT tool was developed to foster more productive interactions between health care professionals and family caregivers. Because it was developed with direct input from family caregivers, the items are both relevant to actual experience and relatively easy to understand. Psychometric testing supports the hypothesis that the FCAT tool items function as a unidimensional construct with a high level of reliability. The FCAT tool has the potential to guide interventions intended to enhance family caregiver preparation and confidence, and thereby positively influence clinical practice during care transitions.

Patients' and Family Caregivers' Goals for Care During Transitions Out of the Hospital.

The aims of this study were to (a) describe the nature of patients' goals upon discharge from hospital, family caregivers' goals for their loved ones, and family caregivers' goals for themselves; (b) determine the degree of concordance with respect to the three elicited goals; (c) ascertain goal attainment across the three elicited goals; and (d) examine factors predictive of goal attainment. Our findings support the position that eliciting patient and family caregiver goals and promoting goal attainment may represent an important step toward promoting greater patient and family caregiver engagement in their care.

Enhancing the care transitions intervention protocol to better address the needs of family caregivers.

BACKGROUND: Family caregivers play a central role in ensuring the execution of the discharge care plan. OBJECTIVE: To enhance an evidence-based model-the Care Transitions Intervention (CTI)-and to make it more responsive to the needs of family caregivers and determine its impact on a measure of activation. METHODS: Prospective cohort of 83 patient-family caregiver partnerships discharged from hospital. The domains of the CTI were modified to incorporate those areas that family caregivers identified as wanting to feel better prepared and more confident. RESULTS: Family caregivers experienced a mean improvement in activation of 6 points on a 0-10 scale (p < .0001). Sixty-four percent (95% confidence interval [CI], 52-75%) of family caregivers met or exceeded self-identified goals. Transitions Coaches identified 71% (95% CI, 60-80%) of patients as having medication discrepancies or errors after hospital discharge and coached family caregivers on how to respond. The mean 3-item Care Transitions Measure score on a 0-100 scale was 80.89 (95% CI, 76.62-85.16). Almost all (99%) (95% CI, 92-100%) participants would recommend the model to a friend of family member. DISCUSSION: The enhanced family caregiver CTI significantly improved activation, quality, goal achievement, satisfaction, and medication safety. The enhanced family caregiver CTI may have application in improving the hospital discharge experience.

Family caregivers' experiences during transitions out of hospital.

BACKGROUND: Family caregivers play a central yet under recognized role in ensuring quality and safety during a loved one's transition out of the hospital. OBJECTIVE: To explore facilitators and challenges family caregivers face in assuming postdischarge family caregiving roles and completing complex care tasks. METHODS: A qualitative study recruited 32 participants from 4 sites. Participants were unpaid family caregivers whose loved one was recently discharged from an acute care hospital. A modified Grounded Theory approach was used. RESULTS: Five central themes emerged from the analysis: (1) family caregivers' contributions to the care of their loved one unfold along on a spectrum where the readiness, willingness, and ability of both parties are often dynamic; (2) family caregivers have unique and potentially incongruent goals from those of the patient; (3) family caregivers feel unprepared for postdischarge medication management; (4) family caregivers encouragement to assert an identity; (5) family caregivers often assume the responsibility for the sequencing of posthospital care plan tasks and anticipating next steps. CONCLUSION: Family caregivers provided valuable insights into the challenges they face facilitating their loved ones' transitions. These findings may directly inform the design and testing of an evidence-based intervention to enhance their roles.