Transitional care refers to health services that help patients and families manage care at home after a hospital stay. Because transitional care was designed for patients in cities, it may not meet the needs of patients in rural towns.
In this study, we invited patients, their families, and nurses in rural towns to tell us how to make transitional care better meet their needs. We also asked them to tell us what they think about strategies that can improve patients’ ability to function and manage their care after discharge. Some key findings of this study were:
- Patients and families felt generally unprepared to manage care and recovery after hospitalization
- Patients, their families, and nurses were generally positive about the strategies to improve patients’ ability to function and manage care
- One of the most pressing unmet needs for families was knowing how to identify the signs of worsening health in their relative and what to do about them
- Families experience several challenges to helping their relatives be physically active after hospital discharge.
Policy makers and administrators can use the findings to improve transitional care.
The expected impacts include:
- Patients and families who are better prepared to manage care after hospital discharge
- Fewer hospital readmissions
- Cost savings to the healthcare system.
