Engaging patients and caregivers to design transitional care management services at a minority serving institution

Iulia D. Ursan, Jerry A. Krishnan, A. Simon Pickard, Elizabeth Calhoun, Robert Didomenico, Valentin Prieto-Centurion, Jamie B. Sullivan, Lauren Valentino, Mark V. Williams, Min Joo

Research output: Contribution to journalArticlepeer-review

12 Scopus citations


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.

Original languageEnglish (US)
Pages (from-to)352-365
Number of pages14
JournalJournal of health care for the poor and underserved
Issue number1
StatePublished - Feb 2016


  • Care transition
  • Patient navigator
  • Readmission
  • Transitional care management

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health


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