Results Summary

What was the research about?

After a hospital stay, patients may go home to recover or to another healthcare site, such as a nursing home. But if they don’t get the right support, patients may have problems with recovery and need to return to the hospital. Hospitals use different strategies to help patients during care transitions.

In this project, the research team did three studies. Study 1 asked patients and caregivers what matters most to them during a care transition. Studies 2 and 3 compared the effect of groups of care transition strategies that hospitals may use on patient health, including how often patients returned to the hospital within 30 days. Study 3 also looked at how patients rated their health at least 51 days after leaving the hospital.

What were the results?

What mattered most to patients and caregivers was to

  • Feel cared for by providers
  • Know who oversees the care transition
  • Feel ready to take care of themselves when leaving the hospital

Hospitals that used strategies to share information among healthcare sites had larger decreases in the rate of patients who returned within 30 days than hospitals that didn’t use them.

Compared with patients from hospitals using other strategies, those from hospitals that worked to improve trust in hospitals, use plain language, and coordinate care were more likely to report improved

  • Physical and mental health
  • Sleep quality
  • Ability to do daily activities
  • Pain levels

These patients were also less likely to return to the hospital or emergency room. But they were more likely to spend at least one day at another healthcare site in the 30 days after leaving the hospital.

What did the research team do?

Study 1. The research team interviewed 138 patients and 110 family caregivers from six health networks. The team used these results and reviewed published studies to make a list of care transition strategies.

Study 2. The research team surveyed 370 hospitals about the strategies they use. The study included health records for 2,369,601 patients with Medicare who were in one of these hospitals between 2009 to 2014. The team looked at who returned within 30 days. Among patients, 84 percent were white, 11 percent were black, and 5 percent were another or unknown race. Also, 57 percent were women.

Study 3. The research team surveyed 42 hospitals on their use of strategies. At least 51 days after leaving these hospitals, 7,939 patients completed surveys about hospital discharge and their health. Among patients, 79 percent were white, 10 percent were black, and 11 percent were other or unknown races. The average age was 72, and 53 percent were women.

Patients, caregivers, and healthcare professionals helped design and conduct the study.

What were the limits of the study?

Factors other than the care transition strategies may have affected the study results.

Future studies could look further at how health providers can support care transitions.

How can people use the results?

Hospitals can use these results when planning care transitions.

How this project fits under PCORI’s Research Priorities
PCORI identified transitional care services between the hospital and home or another facility as an important research topic. Patients, clinicians, and others wanted to learn: What groups of transitional care services meet patients’ needs as they move from hospitals to other care settings? To help answer this question, PCORI launched an initiative in 2014 on The Effectiveness of Transitional Care. The initiative funded this research project.

Final Research Report

View this project's final research report.

Stories and Videos

Peer-Review Summary

Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.

The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments. 

Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:

  • The reviewers asked for clarification on the types of care transitions addressed in the study stating that the study appears to address care transitions broadly, but some parts of the report seem to focus more narrowly on transitions from hospital to home, for example. The researchers responded that the project focused on transitions from hospital to home or other sites but commented that they believe their findings likely apply to many types of patient care transitions.
  • The reviewers commented that the use of odds ratios to depict the association between care transitions and several outcomes of interest could be misinterpreted, suggesting instead that the researchers report relative risk to better convey the relationship between transition strategies and certain outcomes. The researchers agreed with the reviewers, saying that when a particular outcome is common, it would be easier to interpret the results if they indicated relative risk of the outcome instead of absolute risk or odds. Therefore, the researchers changed the results tables in the report to display relative risk and moved the tables with odds ratios to an appendix.
  • The reviewers asked about the possibility that the prospective study described in the report could have detected some spurious associations because of a large number of comparisons. The researchers reported that they used a more stringent probability threshold of 0.01 to detect statistical significance rather than the more conventional 0.05 by adjusting for comparing across five groups.
  • The reviewers commented that the hospitals chosen for the study might not be entirely representative of hospitals throughout the nation, noting that for-profit hospitals were largely excluded from the study and rural hospitals were overrepresented. The researchers agreed that for-profit hospitals were underrepresented in their study, but stated that when they visited the hospitals in the study, they found that barriers and facilitators of care transitions were similar among different healthcare organizations, regardless of ownership. The researchers added that they purposely oversampled rural hospitals because such hospitals usually have fewer resources and face more challenges in transitional care.  Also, the researchers explained that they  could only obtain a representative number of rural patients by oversampling rural hospitals because these institutions tend to be smaller. The researchers did acknowledge the possibility that their sampling strategy, which focused on hospitals already participating in transitional care programs, could be biased. However, the researchers said they found that the characteristics of hospitals in the study were generally comparable to hospitals nationwide.
  • The reviewers asked the researchers to describe how they reached thematic saturation in the qualitative work that was part of this project. The researchers explained that data analysis was ongoing during data collection for patient and caregiver focus groups, so they continued recruiting until they reached theoretical saturation. For provider focus groups and hospital site visits, the researchers did not attempt to reach thematic saturation. They did this for the former because the variability among providers, sites, and procedures would make saturation unfeasible and for the latter because thematic saturation was not a goal for the hospital site visits since this work was a pilot phase to prepare for a larger effort. However, the researchers believed that they did reach thematic saturation in these site visits based on the repetition of barriers and facilitators to transitional care programs identified by the site visit participants. In addition, the researchers explained that they validated the themes brought up in the qualitative substudies by discussing their findings with people at the sites visited, with research team members, and with patient stakeholders in the study.

Conflict of Interest Disclosures

Project Information

Mark V. Williams, MD, MHM, FACP
University of Kentucky
Project ACHIEVE (Achieving Patient-Centered Care and Optimized Health In Care Transitions by Evaluating the Value of Evidence)

Key Dates

September 2014
January 2021

Study Registration Information


Has Results
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Health Conditions Health Conditions These are the broad terms we use to categorize our funded research studies; specific diseases or conditions are included within the appropriate larger category. Note: not all of our funded projects focus on a single disease or condition; some touch on multiple diseases or conditions, research methods, or broader health system interventions. Such projects won’t be listed by a primary disease/condition and so won’t appear if you use this filter tool to find them. View Glossary
Populations Populations PCORI is interested in research that seeks to better understand how different clinical and health system options work for different people. These populations are frequently studied in our portfolio or identified as being of interest by our stakeholders. View Glossary
Intervention Strategy Intervention Strategies PCORI funds comparative clinical effectiveness research (CER) studies that compare two or more options or approaches to health care, or that compare different ways of delivering or receiving care. View Glossary
State State The state where the project originates, or where the primary institution or organization is located. View Glossary
Last updated: January 20, 2023