Understanding experiences of patients and family caregivers in the Mayo Clinic Care Transitions program: a qualitative study

Figures & data

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Home visit: description by patients and caregivers about what their home visit entails, the process, and what happens during the home visit. The home visit emerged as the central theme and most important component of the MCCT program.

• Time: patients and caregivers spoke of the time NPs take during the home visit, as opposed to being rushed during an office visit.

• Medication: patients and caregivers spoke about medication discussions, reconciliation, and adjustments during the home visit.

• Food: descriptions were made about diet and food and the importance that diet has on chronic conditions.

• Education: NPs provided education or information that the patients felt they did not get while in the hospital or were too confused or ill to absorb.

• Home turf: part of the importance of the home visit, patients talk about being in their home, and the ease of asking questions in their own environment. The freedom to talk about things in the comfort of their own home on their own terms.

NPs’ characteristics: patients and caregivers spoke of the MCCT NPs being kind, patient, and knowledgeable. The description of the NPs themselves and how they interacted with the patients and caregivers emerged as an important characteristic of the program in general.

• Whole person: talk of how the NP addresses issues other than the cause of the hospitalization. What the NP does that affects other areas of the patient’s care.

• Physical: NP addressing other health concerns aside from the recent hospitalization.

• Coordination: NP addressing social needs or coordination of services that will help the patient aside from medical issues, social support, or errands.

• QOL: how the NP visits affects the patients’ QOL or helps them achieve their activities of daily living or meet their personal goals.

Abbreviations: NPs, nurse practitioners; MCCT, Mayo Clinic Care Transitions; QOL, quality of life.

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Caregivers: caregivers talk of less worry and stress by having someone come into the home.

Caregivers’ communication: caregivers talk of improved communication and ability to talk to the NP and ask questions.

NPs’ patient-centered care: discussion of the NP coordinating care and making appointments, advocating for their specific needs, and listening to their needs as an individual.

Self-management/patient activation: patients discuss their willingness to learn to self-manage or take steps to manage their condition. This is important in the type of patient who might be best suited for the MCCT program.

Abbreviations: MCCT, Mayo Clinic Care Transitions; NP, nurse practitioner.

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The home visit: being on the patient’s “home turf.” Providers felt that doing the visit at home provided some improvement in care.

End-of-life care, palliative care, future care: providers recognized the home visit as an opportunity to discuss end-of-life care issues with the patient.

Continuity of care, relationships, and the MCCT team: the home visit was also described as a way to maintain consistency and continuity of care following a hospital stay.

Passion for this patient population: discussion of the MCCT program led the providers to talk about their passion for working with this patient population, often composed of geriatric patients with failing health.

Staffing, phone issues, communication: staffing is often an issue. Not being able to enroll patients who qualify and would benefit, being able to provide coverage 24 hours a day and 7 days a week for MCCT patients, and having access to care providers through telephone contact are often issues as well.

Abbreviation: MCCT, Mayo Clinic Care Transitions.

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“Home turf”

“But being at home, your seem to be a lot more comfortable and able to talk about things, and they understand, you know, that you are also a mother and and a grandmother and all that, that, you know, that there’s a lot of things going on in my life … And that made it a lot easier.” [Patient 12]

Nurse

“There … [nurse practitioner] runs the show … And, ah, I mean that as as an honest thing; that’s you need somebody that’s a primary. To actually sort of funneling everything through 1 person …” [Patient 18]

“Um, 1 strength, um, they’re very very considerate and very very caring, um. Their main purpose of being here is to, you know, listen to their patients’ needs and she did that. [chuckles] You know, she did that very well; she listened to mom’s concerns and and her needs and she helped us with a lot of stuff, so; wonderful lady.” [Caregiver 12]

Whole person

“How much it was covered by my insurance, how I go about finding out that stuff, and actually … [nurse] was the one that told me to probably call a certain place; I’ve got it written down over here, but they could give me a little bit better help on that.” [Patient 1]

“Yeah, I get in these depressed moods, and, you know, being a homebody I can’t associate with people, and you know I have them come and visit, you know it’s a one on one, you know, I’ll get a one on one with somebody … Feel like a human instead of a, oh, homebound rat or something.” [Patient 17]

“From what I was coming out of the hospital, absolutely … Oh, I mean, I just wasn’t very good when I came out the hospital … I got home and, ah, I’m sitting in a chair but I had to, I don’t know, who would have made all these appointments to see the right people or get me on the right prescription? [Interviewer: So it sounds like you’ve almost had um this ah ah personally nurse in a way.] Oh, in a sense you got a whole group of ‘em. You got exercise, you got daily nursing … You got [a nurse] who coordinates all of that stuff and comes out herself. … Yeah, and resting in my own bed, my daughter says.” [Patient 18]

“Well, you know that there there a lot of, ah, things that affect that because, ah, depending on what I was in the hospital before for the last time I was, I think the last year I was in the hospital for pneumonia again and heart breathing and, ah, it was tougher when I got out because, you know, it was basically just discharge, go home, and then try to get back into the groove without any support system. And that’s what I look at the care transition as, is a support system for you to basically transition back into your normal life.” [Patient 7]