Are we “missing the big picture” in transitions of care? Perspectives of healthcare providers managing patients with unplanned hospitalization

Student Author(s)

Hawa Abu; Nathaniel Erskine; Joanne Lewis

UMMS Affiliation

Department of Quantitative Health Sciences; Graduate School of Nursing; Division of Cardiovascular Medicine, Department of Medicine

Publication Date


Document Type



Health Services Administration | Health Services Research | Nursing



Healthcare providers play a critical role in the care transitions. Therefore, efforts to improve this process should be informed by their perspectives.


The study objective was to explore the factors that negatively/positively influence care transitions following an unplanned hospitalization from the perspective of healthcare providers.


A qualitative study using semi-structured interviews conducted between February and September of 2016 at a single academic medical center. We enrolled fifteen healthcare providers from multiple disciplines involved in the management of patients experiencing an unplanned hospitalization. Respondents shared their experiences with care transitions and identified factors within and outside of the discharging health facility that impede or facilitate this process. Transcribed interviews were analyzed using emerging themes from the interviews.


We identified six themes and associated subthemes from the interviews on factors that influence care transitions. Three themes focused on factors within the discharging healthcare facility: untailored and overloaded patient discharge information, timing of the post-discharge care conversation, provider-to-patient and provider-to-provider miscommunication. The other three themes were related to external factors including caregiver involvement, having a safe and stable housing environment, and access to healthcare and community resources. Providers discussed how these factors positively/negatively influence the hospital-to-home transition.


Our study identifies factors within and outside the discharging healthcare facility that influence care transitions, ultimately affect patient-centered outcomes and provider satisfaction with delivered care. Strategies aimed at improving the quality of care transitions should address these barriers and actively engage healthcare providers who are pivotal in care transitions.


Care transitions, Healthcare providers, Patient discharge, Caregiver involvement, Health care communication

DOI of Published Version



Appl Nurs Res. 2018 Dec;44:60-66. doi: 10.1016/j.apnr.2018.09.006. Epub 2018 Sep 19. Link to article on publisher's website

Journal/Book/Conference Title

Applied Nursing Research

Related Resources

Link to article in PubMed

PubMed ID