title: 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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  A well-coordinated collaborative Patient Care Circle is fundamental to ensuring safe care transitions.
authors.affiliation: Department of Medicine, Weill Cornell Medical College, New York, New York.
authors.forename: Jennifer I
authors.initials: JI
authors.lastname: Lee
authors.forename: Christine
authors.initials: C
authors.lastname: Cutugno
authors.forename: Sean P
authors.initials: SP
authors.lastname: Pickering
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Press
authors.forename: Joshua E
authors.initials: JE
authors.lastname: Richardson
authors.forename: Michelle
authors.initials: M
authors.lastname: Unterbrink
authors.forename: Mary Elizabeth
authors.initials: ME
authors.lastname: Kelser
authors.forename: Arthur T
authors.initials: AT
authors.lastname: Evans
mesh_terms: D000046:Academic Medical Centers / Q000592:standards / Q000706:statistics & numerical data; D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D003266:Continuity of Patient Care / Q000458:organization & administration* / Q000592:standards; D005260:Female; D017144:Focus Groups; D006786:Hospitals, Urban / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D033183:Interdisciplinary Communication; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D009519:New York City; D010348:Patient Care Team / Q000458:organization & administration / Q000592:standards*; D062526:Patient Navigation / Q000379:methods / Q000458:organization & administration / Q000592:standards*; D010359:Patient Readmission / Q000592:standards* / Q000706:statistics & numerical data; D010361:Patients / Q000523:psychology / Q000706:statistics & numerical data; D036301:Qualitative Research; D012720:Severity of Illness Index