title: A "Simple" Evidence-Based Intervention to Improve Care Transitions for Frail Patients with Complex Health Conditions: Why Didn't It Work as Expected?
abstract: The transition from hospital to home is a vulnerable period for patients with complex conditions, who are often frail, at risk for adverse events and unable to navigate a system of poorly coordinated care in the post-discharge period. Care transition interventions are seen as effective care coordinating mechanisms for reducing avoidable adverse events associated with the transition of the patient from the hospital to the home. A study was undertaken to evaluate the effectiveness of a care transition intervention involving a hand-off between a hospital-based care transitions nurse and a community-based rapid response nurse. Two focus groups were held, one involving rapid response nurses and the other involving care transition nurses. Individual interviews were conducted with the managers (n= 2) and executives (n= 2) to identify the factors that facilitated or were barriers to its implementation. Using thematic content analysis, it was found that the effectiveness of transitional coordination efforts was thwarted by ineffective communication, which affected the quality of the underlying relationships between the two teams. Other barriers to achieving the desired outcomes included the following: issues of role clarity, role awareness and acceptance, the adequacy and reinforcement of coordinating mechanisms, the effectiveness of the information exchange protocols and the absence of shared measures of accountability. Clinical integration initiatives have fewer human resource and financial implementation barriers compared with organizational integration efforts but are complex undertakings requiring clear alignment between organizations, shared accountability measures, effective communication processes and relationships of trust and respect between interprofessional teams.
authors.affiliation: Vice president of Patient Services, Clinical Transformation and chief nursing executive at Health Sciences North in Sudbury, ON. He can be reached by email at: dmcneil@hsnsudbury.ca.
authors.forename: David
authors.initials: D
authors.lastname: McNeil
authors.affiliation: Professor of Rural Health and dean and CEO of the Northern Ontario School of Medicine at Laurentian University and Lakehead University in Thunder Bay, ON.
authors.forename: Roger
authors.initials: R
authors.lastname: Strasser
authors.affiliation: Associate professor in the School of Rural and Northern Health at Laurentian University in Sudbury, ON.
authors.forename: Nancy
authors.initials: N
authors.lastname: Lightfoot
authors.affiliation: Senior research fellow and professor emeritus at the Centre for Rural and Northern Health Research at Laurentian University in Sudbury, ON.
authors.forename: Raymond
authors.initials: R
authors.lastname: Pong
mesh_terms: D003142:Communication; D015897:Comorbidity; D003266:Continuity of Patient Care / Q000458:organization & administration; D055317:Evidence-Based Practice / Q000458:organization & administration*; D017144:Focus Groups; D006801:Humans; D009726:Nurses / Q000458:organization & administration*; D009864:Ontario; D010351:Patient Discharge; D015397:Program Evaluation