RESUMO
BACKGROUND: Transitional care (TC) involves multiple organizations as patients transition from hospitals. Collaboration to reduce readmissions has been encouraged by government initiatives. As part of Project ACHIEVE, a comparative TC study, we sought provider perspectives on TC improvement efforts. METHODS: We aimed to identify perceived problems that drove improvement efforts, influences on interventions implemented, facilitators or barriers to desired outcomes, and sustainability. Investigators interviewed 63 representatives from collaborative improvement efforts across 13 states in 2015. Directed content analysis was performed, with inductive coding as insights emerged. Data was also analyzed for differences in participant perceptions, such as the organization represented, geographic characteristics, and source of funding for interventions. RESULTS: Participants in semi-structured interviews included physicians, nurses, care navigators, and administrators from hospitals, nursing facilities, community-based organizations, and medical practices. Participants reported that changing reimbursement practices and readmissions penalties drove TC efforts, and common problems they sought to address included insufficient inter-provider communication, medication management, and challenges related to chronic condition management. Solutions implemented were often adapted according to community and setting characteristics and population factors. Findings also suggest differences in the types of interventions implemented according to funding sources, which also impacted the ability to sustain these interventions. CONCLUSIONS: Cross-site collaboration, communication, and partnership among stakeholders is essential to effective transitional care. Collaboration led to shared understanding among stakeholders of health care and support services available in the community. Coalition-based work also facilitated trust among partners which led to expansion and sustainment of TC efforts. Unmet social needs of patients are a barrier. IMPLICATIONS: Opportunities exist for increased and improved collaboration among clinical providers with community-based and social services organizations. Increased involvement of primary care providers in such collaborations would improve communication with both the patient and involved providers. Communities with external funding were more likely to implement evidence-based interventions, while those relying on institutional support addressed identified problems with more targeted interventions.
