{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,11]],"date-time":"2026-06-11T17:50:29Z","timestamp":1781200229466,"version":"3.54.1"},"reference-count":35,"publisher":"SAGE Publications","issue":"5","license":[{"start":{"date-parts":[[2013,10,1]],"date-time":"2013-10-01T00:00:00Z","timestamp":1380585600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Population Health Management"],"published-print":{"date-parts":[[2013,10]]},"abstract":"<jats:p>\n                    Readmissions to the hospital are common and costly, often resulting from poor care coordination. Despite increased attention given to improving the quality and safety of care transitions, little is known about patient and provider perspectives of the transitional care needs of rehospitalized Veterans. As part of a larger quality improvement initiative to reduce hospital readmissions, the authors conducted semi-structured interviews with 25 patients and 14 of their interdisciplinary health care providers to better understand their perspectives of the transitional care needs and challenges faced by rehospitalized Veterans. Patients identified 3 common themes that led to rehospitalization: (1) knowledge gaps and deferred power; (2) difficulties navigating the health care system; and (3) complex psychiatric and social needs. Providers identified different themes that led to rehospitalization: (1) substance abuse and mental illness; (2) lack of social or financial support and homelessness; (3) premature discharge and poor communication; and (4) nonadherence with follow-up. Results underscore that rehospitalized Veterans have a complex overlapping profile of real and perceived physical, mental, and social needs. A paradigm of disempowerment and deferred responsibility appears to exist between patients and providers that contributes to ineffective care transitions, resulting in readmissions. These results highlight the cultural constraints on systems of care and suggest that process improvements should focus on increasing the sense of partnership between patients and providers, while simultaneously creating a culture of empowerment, ownership, and engagement, to achieve success in reducing hospital readmissions. (\n                    <jats:italic toggle=\"yes\">Population Health Management<\/jats:italic>\n                    2013;16:326\u2013331)\n                  <\/jats:p>","DOI":"10.1089\/pop.2012.0104","type":"journal-article","created":{"date-parts":[[2013,4,6]],"date-time":"2013-04-06T14:06:33Z","timestamp":1365257193000},"page":"326-331","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":17,"title":["Transitional Care Challenges of Rehospitalized Veterans: Listening to Patients and Providers"],"prefix":"10.1177","volume":"16","author":[{"given":"Caroline","family":"Stephens","sequence":"first","affiliation":[{"name":"San Francisco VA Medical Center"},{"name":"University of California"},{"name":"San Francisco VA Medical Center"},{"name":"John A. Hartford Foundation\/Atlantic Philanthropies Claire M. Fagin Fellow"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nathan","family":"Sackett","sequence":"additional","affiliation":[{"name":"San Francisco VA Medical Center"},{"name":"Berkeley\/University of California San Francisco Joint Medical Program"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Read","family":"Pierce","sequence":"additional","affiliation":[{"name":"San Francisco VA Medical Center"},{"name":"University of California San Francisco"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David","family":"Schopfer","sequence":"additional","affiliation":[{"name":"San Francisco VA Medical Center"},{"name":"San Francisco VA Medical Center"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gabriela","family":"Schmajuk","sequence":"additional","affiliation":[{"name":"San Francisco VA Medical Center"},{"name":"University of California San Francisco"},{"name":"San Francisco VA Medical Center"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicholas","family":"Moy","sequence":"additional","affiliation":[{"name":"San Francisco VA Medical Center"},{"name":"San Francisco VA Medical Center"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Melissa","family":"Bachhuber","sequence":"additional","affiliation":[{"name":"San Francisco VA Medical Center"},{"name":"University of California San Francisco"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Margaret I.","family":"Wallhagen","sequence":"additional","affiliation":[{"name":"University of California"},{"name":"San Francisco VA Medical Center"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sei J.","family":"Lee","sequence":"additional","affiliation":[{"name":"San Francisco VA Medical Center"},{"name":"San Francisco VA Medical Center"},{"name":"University of California San Francisco"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2013,10,1]]},"reference":[{"key":"e_1_3_3_2_2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMsa0803563"},{"key":"e_1_3_3_3_2","doi-asserted-by":"publisher","DOI":"10.1377\/hlthaff.2011.0041"},{"key":"e_1_3_3_4_2","doi-asserted-by":"publisher","DOI":"10.1111\/j.1475-6773.2004.00298.x"},{"key":"e_1_3_3_5_2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMhpr0706165"},{"key":"e_1_3_3_6_2","doi-asserted-by":"publisher","DOI":"10.7326\/0003-4819-153-11-201012070-00010"},{"key":"e_1_3_3_7_2","unstructured":"Patient Protection and Affordable Care Act of 2010Pub.L. No. 111-48 24 Stat119."},{"key":"e_1_3_3_8_2","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2011.1561"},{"key":"e_1_3_3_9_2","doi-asserted-by":"publisher","DOI":"10.1001\/archinte.166.17.1822"},{"key":"e_1_3_3_10_2","doi-asserted-by":"publisher","DOI":"10.1111\/j.1532-5415.2004.52202.x"},{"key":"e_1_3_3_11_2","doi-asserted-by":"publisher","DOI":"10.1001\/jama.281.7.613"},{"key":"e_1_3_3_12_2","doi-asserted-by":"publisher","DOI":"10.7326\/0003-4819-150-3-200902030-00007"},{"key":"e_1_3_3_13_2","unstructured":"Society of Hospital Medicine. Project BOOST Mentoring Program. www.hospitalmedicine.org\/. 2012 April 18."},{"key":"e_1_3_3_14_2","unstructured":"American College of Cardiology Institute for Healthcare Improvement. Hospital to Home (H2H) national quality improvement initiative. www.h2hquality.org. 2012 April 18."},{"key":"e_1_3_3_15_2","unstructured":"Institute for Healthcare Improvement. STate Action on Avoidable Rehospitalizations (STAAR) initiative. http:\/\/www.ihi.org\/offerings\/Initiatives\/STAAR\/Pages\/default.aspx. 2012 April 18."},{"key":"e_1_3_3_16_2","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2011.1515"},{"key":"e_1_3_3_17_2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMp038222"},{"key":"e_1_3_3_18_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.psym.2011.03.005"},{"key":"e_1_3_3_19_2","doi-asserted-by":"publisher","DOI":"10.1001\/jama.285.2.200"},{"key":"e_1_3_3_20_2","doi-asserted-by":"publisher","DOI":"10.2105\/AJPH.2005.067850"},{"key":"e_1_3_3_21_2","doi-asserted-by":"publisher","DOI":"10.1080\/10852350902735734"},{"key":"e_1_3_3_22_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.apnr.2005.05.004"},{"key":"e_1_3_3_23_2","doi-asserted-by":"publisher","DOI":"10.1177\/1054773804263165"},{"key":"e_1_3_3_24_2","doi-asserted-by":"publisher","DOI":"10.1046\/j.1365-2648.2001.01873.x"},{"key":"e_1_3_3_25_2","doi-asserted-by":"publisher","DOI":"10.1046\/j.1365-2648.2003.02616.x"},{"key":"e_1_3_3_26_2","doi-asserted-by":"publisher","DOI":"10.1067\/mcm.2003.49"},{"key":"e_1_3_3_27_2","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.323.7313.625"},{"key":"e_1_3_3_28_2","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs.2010.045955"},{"key":"e_1_3_3_29_2","first-page":"e71","article-title":"Patient-centered medical home demonstration: A prospective, quasi-experimental, before and after evaluation","volume":"15","author":"Reid RJ","year":"2009","unstructured":"Reid RJ, , Fishman PA, , Yu O et al. Patient-centered medical home demonstration: A prospective, quasi-experimental, before and after evaluation. Am J Manag Care, 2009; 15:e71\u2013e87.","journal-title":"Am J Manag Care"},{"key":"e_1_3_3_30_2","unstructured":"US Department of Veterans Affairs. New model of primary care being studied across VA. http:\/\/www.research.va.gov\/resources\/pubs\/docs\/va_research_currents_july-aug_10.pdf. 2012 December 7."},{"key":"e_1_3_3_31_2","doi-asserted-by":"publisher","DOI":"10.1007\/s11606-012-2016-6"},{"key":"e_1_3_3_32_2","doi-asserted-by":"crossref","unstructured":"Rollnick S Miller WM Butler CC. Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York: Guilford Press 2008.","DOI":"10.1080\/15412550802093108"},{"key":"e_1_3_3_33_2","doi-asserted-by":"publisher","DOI":"10.1002\/jclp.20638"},{"key":"e_1_3_3_34_2","doi-asserted-by":"publisher","DOI":"10.1080\/02813430903072876"},{"key":"e_1_3_3_35_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.cpr.2009.02.001"},{"key":"e_1_3_3_36_2","doi-asserted-by":"publisher","DOI":"10.1146\/annurev.clinpsy.1.102803.143833"}],"container-title":["Population Health Management"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.sagepub.com\/doi\/full-xml\/10.1089\/pop.2012.0104","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1089\/pop.2012.0104","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1089\/pop.2012.0104","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,2]],"date-time":"2026-05-02T01:21:49Z","timestamp":1777684909000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.sagepub.com\/doi\/10.1089\/pop.2012.0104"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2013,10]]},"references-count":35,"journal-issue":{"issue":"5","published-print":{"date-parts":[[2013,10]]}},"alternative-id":["10.1089\/pop.2012.0104"],"URL":"https:\/\/doi.org\/10.1089\/pop.2012.0104","relation":{},"ISSN":["1942-7891","1942-7905"],"issn-type":[{"value":"1942-7891","type":"print"},{"value":"1942-7905","type":"electronic"}],"subject":[],"published":{"date-parts":[[2013,10]]}}}