Investigators:
Dr. Ny'Nika McFadden and Dr. Gretchen Holmes
Research Pillar(s):
Problem
For patients living with chronic conditions such as diabetes, the transition from hospital to home is often one of the most vulnerable points in their care journey. Breakdowns in communication, unclear discharge instructions, limited access to follow-up care, and structural barriers within the healthcare system can disrupt continuity of care and increase the risk of complications or hospital readmissions.
Outside the hospital, patients may also face challenges related to health literacy, transportation, cost of care, and other social determinants of health that affect their ability to manage their condition effectively. When patients leave the hospital without clear, accessible information and coordinated support, their safety, health outcomes, and overall quality of life are at risk.
Solution
This project centers patients’ voices to identify practical, evidence-based solutions that strengthen continuity of care across inpatient and outpatient settings. By examining patients’ lived experiences with structural and communication barriers, the research team will identify opportunities to improve discharge processes, care coordination, and patient support systems.
The project also evaluates how health literacy and social determinants of health shape patients’ ability to manage chronic disease beyond the clinical setting. Findings will inform the development of targeted, patient-centered health literacy interventions designed to improve understanding, empower self-management, reduce hospital readmissions, and build greater trust in the healthcare system.
“When we listen to patients’ experiences, we uncover the real barriers affecting safe transitions and chronic disease management. This research is about turning those insights into practical solutions that strengthen continuity of care and empower patients beyond the hospital.”
