These findings suggest that encouraging patients
and their caregivers to assert a more active role in
their care transitions results in reduced rehospitalization
rates. A possible explanation for this finding is
that the transition coach and personal health record
enabled patients and caregivers to ensure that greater
proportions of their needs were being met during this
vulnerable time. To better understand which of the
different components of the model were regarded as
most helpful by the intervention patients, an adjunctive
qualitative descriptive study29 was conducted. The
primary findings of that study suggest that the intervention
led to improved self-management knowledge
and skills for many patients, primarily in the areas of
medication management, condition management, and
patient confidence about what was required of them
during the transition and beyond. The findings suggest
that the continuity of the coaching relationship
fostered a sense of caring, safety, and predictability
about the transition, which contributed to greater
patient investment in the program.