The patient care circle: a descriptive framework for understanding care transitions.

Abstract

BACKGROUND: Reducing hospital readmissions depends on ensuring safe care transitions, which requires a better understanding of the challenges experienced by key stakeholders. OBJECTIVE: Develop a descriptive framework illustrating the interconnected roles of patients, providers, and caregivers in relation to readmissions. DESIGN: Multimethod qualitative study with 4 focus groups and 43 semistructured interviews. Multiple perspectives were included to increase the trustworthiness (internal validity) and transferability (external validity) of the results. Data were analyzed using grounded theory to generate themes associated with readmission. SETTING/PATIENTS: General medicine patients with same-site 30-day readmissions, their family members, and multiple care providers at a large urban academic medical center. RESULTS: A keynote generated from the multiperspective responses was that care transitions were optimized by a well-coordinated multidiscipline support system, described as the Patient Care Circle. In addition, issues pertaining to readmissions were identified and classified into 5 main themes emphasizing the necessity of a coordinated support network: (1) teamwork, (2) health systems navigation and management, (3) illness severity and health needs, (4) psychosocial stability, and (5) medications. CONCLUSION: A well-coordinated collaborative Patient Care Circle is fundamental to ensuring safe care transitions.