title: Facilitators and Barriers to Implementing Transitional Care Managers Within a Public Health Care System.
abstract: Transitional care is crucial to ensure quality of care and safety for elderly patients. In the context of health care reforms promoting a shift from a hospital-centered approach to a home care approach, transitional care becomes a vital component and social workers can play an important role in easing transitions. Most recent studies have focused on the development or improvement of transitional care intervention models or tools, but few have addressed implementation issues. In this study, the implementation process of an innovative intervention aiming to integrate transitional care managers (TCMs) from Health and Social Services Centres (HSSC) within two Canadian hospitals was evaluated. Data collection comprised focus groups (n = 8), direct observations, meeting minutes, activity grids and logbooks. To facilitate the implementation of TCMs, decisions were made to clearly indicate their involvement in patients' files and concentrated their efforts on a restricted number of units. Barriers included confusion about target clientele, inequitable information exchange between partners, limited powers regarding coordination of care, and organizational constraints limiting additional measures to improve transitional care. Evaluating implementation processes is crucial to efficiently identify obstacles and apply additional implementation strategies to promote the integration of new practices within the health care system.
authors.affiliation: a Centre for Research and Expertise in Social Gerontology , Integrated Health and Social Services University Network for West-Central Montreal , Côte Saint-Luc , Quebec , Canada.
authors.forename: Mélanie
authors.initials: M
authors.lastname: Couture
authors.affiliation: a Centre for Research and Expertise in Social Gerontology , Integrated Health and Social Services University Network for West-Central Montreal , Côte Saint-Luc , Quebec , Canada.
authors.forename: Martin
authors.initials: M
authors.lastname: Sasseville
authors.affiliation: b Jean Talon Hospital , Integrated Health and Social Services University Network for North Montreal , Montreal , Quebec , Canada.
authors.forename: Valérie
authors.initials: V
authors.lastname: Gascon
mesh_terms: D002170:Canada; D000071959:Case Managers / Q000191:economics / Q000600:supply & distribution*; D003695:Delivery of Health Care / Q000379:methods; D017144:Focus Groups; D006801:Humans; D011634:Public Health / Q000379:methods; D000069341:Transitional Care / Q000592:standards*; D000078329:Workforce
keywords: Home care; hospital; implementation; transitional care