Family caregivers' experiences during transitions out of hospital.

Background: Family caregivers play a central yet under recognized role in ensuring quality and safety during a loved one's transition out of the hospital.

Objective: To explore facilitators and challenges family caregivers face in assuming postdischarge family caregiving roles and completing complex care tasks.

Methods: A qualitative study recruited 32 participants from 4 sites.

Enhancing the care transitions intervention protocol to better address the needs of family caregivers.

Background: Family caregivers play a central role in ensuring the execution of the discharge care plan.

Objective: To enhance an evidence-based model-the Care Transitions Intervention (CTI)-and to make it more responsive to the needs of family caregivers and determine its impact on a measure of activation.

Methods: Prospective cohort of 83 patient-family caregiver partnerships discharged from hospital.

Disseminating evidence-based care into practice.

The Centers for Medicare and Medicaid Services (CMS) has launched the Partnership for Patients initiative, promising a 20% reduction in readmissions nationally across all payers by December 31, 2013. To address this ambitious goal, CMS has awarded grants to Hospital Engagement Networks, Pioneer Accountable Care Organizations, and the Community-based Care Transitions Program, as well as instituted new penalties for excessive readmission that began in October 2012. National efforts aimed at realizing this goal are predicated, in part, on our effectiveness in disseminating evidence-based care models into practice to improve outcomes and reduce costs.