JMIR Publications

ABSTRACT

Background:

Transition home after hospitalization involves the potential risk of adverse patient events, such as knowledge deficits related to self-care, medication errors, and readmissions. Despite broad organizational efforts to provide better care transitions for patients, there are challenges in implementing interventions that effectively improve care transition outcomes, as evidenced by readmission rates. Collaborative efforts that require healthcare professionals, patients, and caregivers to work together are necessary to identify gaps associated with transitions of care and generate effective transitional care interventions.

Objective:

This study aims to understand the effectiveness of the Integrated Michigan Patient-Centered Alliance in Care Transitions (I-MPACT) design model of bringing together stakeholders of the healthcare system and providing them with a novel tool that captures the patient perspective (patient journey map).

Methods:

We chose a mixed method of direct patient observations and a participatory design workshop to develop transitional care interventions that serve each hospital’s unique situation and contexts. By applying thematic analysis methods, we analyzed problem statements and proposed interventions collected from the participatory design workshops. Findings showed the patterns of major discussion during the workshop.

Results:

Based on workshop results, we formalized the I-MPACT transition of care model, SAFEDC (socioeconomic, active engagement, follow-up, education, discharge readiness tool, consistency), which other organizations can apply to improve patient experiences in care transition.

Conclusions:

Our study demonstrates the benefits of the participatory design approach in defining challenges associated with transitions of care related to patient discharge and generating sustainable interventions to improve care transitions.