How Do Care Transitions Work?

Abstract

Background: Failure of safe care transitions after hospital discharge results in unnecessary worsening of symptoms, extended period of illness or readmission to the hospital. Objective: The objective of this study was to add to the understanding of the working of care transition interventions between hospital and home through unraveling the contextual elements and mechanisms that may have played a role in the success of these interventions, and by developing a conceptual model of how these components relate to each other. Research Design: This was a qualitative study using in-person, semi-structured interviews, based on realist evaluation methods. Subjects: A total of 26 researchers, designers, administrators, and/or practitioners of both current “leading” care transitions interventions and of less successful care transition intervention studies or practices. Measures: The contextual elements and working mechanisms of the different care transition intervention studies or practices. Results: Three main contextual factors (internal environment, external environment, and patient population) and 7 working mechanisms (simplifiying, verifiying, connecting, translating, coaching, monitoring, and anticipating) were found to be relevant to the outcome of care transition interventions. Context, Intervention, Mechanism, and Outcome (CIMO) configurations revealed that, in response to these contextual factors, care transition interventions triggered one or several of the mechanisms, in turn generating outcomes, including a safer care transition. Conclusion: We developed a conceptual model which explains the working of care transition interventions within different contexts, and believe it can help support future successful implementation of care transition interventions.

Patient-Centered Approaches to Transitional Care Research and Implementation

“…51 Finally, authors Zwart and colleagues present a conceptual framework from their qualitative inquiry that helps us understand the contextual factors and mechanisms that impact successful care transition interventions. 52 The issue concludes with commentaries highlighting future research, practice, and policy directions.…”

“…Zatzick and colleagues trace the historical development of patient-centered policy guidance and describe care transition conceptual frameworks that aim to maximize real-world health care system impacts 51. Finally, authors Zwart and colleagues present a conceptual framework from their qualitative inquiry that helps us understand the contextual factors and mechanisms that impact successful care transition interventions 52. The issue concludes with commentaries highlighting future research, practice, and policy directions.…”

Reducing risks in complex care transitions in rural areas: a grounded theory

“…Older people often have convoluted care needs not only due to their medical conditions but also their cognitive state, which increases the demands on environmental assets (Greenstein et al, 2019 ). An environment like the patient’s home strongly influences CTs (Carman et al, 2021 ; Zwart et al, 2021 ). The risk of readmissions is higher when discharged to home healthcare in an ordinary residence than to a skilled nursing facility (Werner et al, 2019 ).…”

Construção de instrumento de avaliação da transição segura do paciente na alta hospitalar

“…Considera-se a alta hospitalar um período vulnerável, uma vez que cerca de 30% dos pacientes desenvolvem um evento adverso após a alta, incluindo danos leves (por exemplo, náusea, diarreia ou erupção cutânea) e até graves (como sangramento gastrointestinal, delírio ou insuficiência respiratória (3) . Esses eventos adversos podem resultar em piora dos sintomas, aumento do tempo de reabilitação, uso de serviços de emergência ou mesmo readmissão hospitalar (3)(4) .…”