title: Engaging Patients and Caregivers to Design Transitional Care Management Services at a Minority Serving Institution.
abstract: Limited socioeconomic resources contribute to high readmission rates at minority serving institutions (MSIs). A better understanding of patient-level factors and need for patient navigators could inform approaches to enhance care transitions tailored to these vulnerable patient populations. We sought to understand the perspectives of patients and their caregivers about hospital to home transitions from an MSI, as well as their attitudes about patient navigators to facilitate care transitions. We conducted qualitative research using focus groups (FGs)-five disease-specific patient FGs and two caregiver FGs, including 23 patients and 10 caregivers. Findings support the need for additional services to address: (1) gaps in the hospital discharge; (2) socioeconomic resources; (3) access to post-discharge care; (4) patient's health care seeking behaviors; (5) patient anxiety; (6) self-management education; and (7) social supports for patients and caregivers. While caregivers uniformly expressed interest in patient navigators, support for navigators among patients was more variable.
authors.forename: Iulia D
authors.initials: ID
authors.lastname: Ursan
authors.forename: Jerry A
authors.initials: JA
authors.lastname: Krishnan
authors.forename: A Simon
authors.initials: AS
authors.lastname: Pickard
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Calhoun
authors.forename: Robert
authors.initials: R
authors.lastname: DiDomenico
authors.forename: Valentin
authors.initials: V
authors.lastname: Prieto-Centurion
authors.forename: Jamie B
authors.initials: JB
authors.lastname: Sullivan
authors.forename: Lauren
authors.initials: L
authors.lastname: Valentino
authors.forename: Mark V
authors.initials: MV
authors.lastname: Williams
authors.forename: Min
authors.initials: M
authors.lastname: Joo
mesh_terms: D017028:Caregivers; D006801:Humans; D010351:Patient Discharge; D036301:Qualitative Research; D012944:Social Support; D000069341:Transitional Care