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Project ACHIEVE Study Identifies Desired Care Transition Outcomes

WASHINGTON — Recent care transitions research led by the University of Kentucky and supported by Essential Hospitals Institute shows that outcomes most important to patients and families are preparedness, accountability, and feeling cared for by providers.

The findings, from Project ACHIEVE, were published in the May/June edition of the Annals of Family Medicine. The University of Kentucky leads Project ACHIEVE, a five-year, $15 million initiative to evaluate care transition strategies in hospitals. The Patient-Centered Outcomes Research Institute funds the project and Essential Hospitals Institute serves as one of several partnering organizations that help with hospital engagement, recruitment, and dissemination.

The article, “Experiencing Care Transitions from the Patient and Caregiver Perspective,” details the care transition outcomes most important to patients and family caregivers and the processes of care linked to those outcomes.

The results in this article come from focus groups and interviews conducted with 138 patients and 110 family caregivers from California, Colorado, Kentucky, Louisiana, New England, and Pennsylvania.

Major Findings

Patients and family caregivers identified three chief outcomes they desire when undergoing a transition from hospital to home or other care setting:

  • to feel prepared and capable of implementing care plans;
  • unambiguous accountability from the health care system; and
  • to feel cared for and cared about by medical providers.

How can providers help patients and their families achieve the outcomes they desire most? Interviews revealed five care transition services or provider behaviors that were linked to achieving the outcomes patients and their family caregivers identified as most important:

  • providing actionable information;
  • collaborative discharge planning;
  • using empathic language and gestures;
  • anticipating the patient’s needs to support self-care at home; and
  • providing uninterrupted care with minimal handoffs.

Findings from this initial phase of the study revealed that accountability, continuity in care, and caring attitudes from the medical staff are important components of care transitions for patients and their family caregivers. When they experience these components, patients and caregivers perceive their care as excellent. However, in the absence of these components, patients and caregivers might feel unsafe and abandoned.

Questions about Project ACHIEVE may be directed to



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