Table 1 Themes and illustrative quotations

Awareness of patient social complexities

People still have issues going outside the hospital and people have chronic problems, and their hospital stay is just one event in their overall course. #8 second year resident

The whole rotation in general cemented in my mind how difficult transitions of care are and how risky they are especially in the older population. Especially if there’s any sort of social circumstances, whether it be food scarcity or poor social support at home, or desire to stay independent versus continuing what our recommendations would be for safety... #7 first year resident

At the end of the day, sometimes it’s all about, ‘Well no one can take out my dog when I’m in the hospital so I don’t want my appointment.’ So it’s more learning about our patients in accordance of them being sick and in accordance of them being human beings who live in society. They have things to do, bills to pay … so my job was to provide that information. #3 second year resident

Bridging gaps across healthcare settings

The idea of a hospitalist has been very much, ‘we’ll take care of them in the acute setting and then we’ll wash [our] hands of them,’ and getting that outpatient perspective- what’s actually happening with this patient- was helpful in terms of informing the way that I thought about other patient encounters. #2 second year resident

There’s a lot of different people working with the patient, and it takes a lot of different people making a lot of different effort to make sure that everything goes smoothly- you need to keep that in mind when they’re discharged, so I think that was a helpful thing to learn and then reinforce in my everyday process. #9 first year resident

It’s easy to just move on after you’ve discharged a patient, your part is done, but I do think it’s useful to be reminded that these transitions are real people on the other end getting the documentation. What you do echoes in time for that person over weeks or months or maybe their lifetime. #5 second year resident

There are ways that we can have direct communication too, rather than just communicating through notes- as a hospitalist next year, it’s something that I’ll address with the community program that I’m working for- can we have a conference call for high risk patients and identify those? I think I can try to incorporate something very similar where the outpatient providers identify a high risk of re-admitting the patient and work on getting in touch with the hospitalist … see if I can implement that into my future practice. #1 third year resident

Recognizing the value of other disciplines across transitions

I didn’t know that pharmacy and social work were so intertwined in the post discharge care, so I thought that was really helpful that there was a chance to hand off to those people as well in addition to just their provider. #11 second year resident

The case managers included in the call … they’re really the ones who are specializing in care transitions, and are especially knowledgeable about geriatric patient transitions. #1 third year resident

Going over her [patient] medicines after discharge was so helpful because it was like, what do we need to make sure this patient really understands what’s happening and what were the things that led to her bounce backs the first time? Being able to have everybody in the same place to be able to talk about those things was helpful. #2 second year resident

It was really useful having the pharmacist input to say, ‘this medication was actually put in incorrectly,’ and it was nice to know that someone else was looking at this and that things that really could have been near misses didn’t fall through the cracks. #2 second year resident