Perspectives of acute, post-acute, physician and community support providers on community collaborative efforts to improve transitions of care

Brianna Gass, Lacey McFall, Jane Brock, Jing Li, Christine LaRocca, Mark Williams

Research output: Contribution to journalArticlepeer-review


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.

Original languageEnglish
Article number100673
Issue number1
StatePublished - Mar 2023

Bibliographical note

Funding Information:
To encourage cross-setting TC and readmission reduction at the community level, the Centers for Medicare and Medicaid Services (CMS) funded programs such as the national Quality Improvement Organization (QIO) program tasks3 related to care coordination: Integrating Care for Populations and Communities (ICPC) which focused on Medicare Fee for Services beneficiaries, and the Community-based Care Transitions Program (CCTP), which focused on high-risk Medicare beneficiaries.4 Both programs were founded on evidence that high-quality TC improves patient safety. 5–12 Both encouraged healthcare organizations to foster cross-setting collaboration through developing formal or informal coalitions of organizations within the local community that commonly share patient care responsibilities across the care continuum. Through these programs, thousands of hospitals, skilled nursing facilities and communities implemented various TC interventions to improve care transitions. Although these programs share some TC strategies, they vary widely in the degree to which components are implemented, and previous research has not delineated which combinations of program components are most effective or essential to patient-centered outcomes. Project ACHIEVE,1 a PCORI-funded 5-year study, aimed to fill these gaps.Coalitions tapped by this initiative to identify participants for interviews typically included hospital discharge planning staff and nursing home and home health admitting staff, but also could include social workers from multiple levels of care, and representatives from Area Agencies on Aging or other community-based organizations that supply a variety of home-based support services. For the purposes of this paper, we include all such entities under the umbrella term “providers”. Coalitions served as a platform for sharing community data on readmissions incidence, establishing and prioritizing root causes of readmissions, and sharing, developing and integrating care transitions improvement efforts. The CCTP additionally provided financial incentives to community-based organizations (CBO) capable of delivering in-home supports to vulnerable patients after hospital discharge. However, even within these funded initiatives, participating health care organizations often struggled and continue to struggle with implementation and sustainment of robust improvement processes across multi-institution efforts, and with improving patient outcomes. 27–30 Due to their crucial role in implementing and sustaining cross-setting collaboration, providers’ perspectives on collaborative TC programs are vital to understanding these efforts.Interventions were selected based on population characteristics of the community, notably socioeconomic status and education. Communities also seemed to select interventions closely matched to problems previously identified through root cause analysis. Providers serving lower-income, less educated populations cited the lack of community support as a root cause, and selected interventions (i.e., referral to social services, use of community health workers) based on these specific population needs. The availability of funding for TC work influenced the nature and scope of interventions implemented in communities. Those with funding for collaborative work (e.g., CCTP, Health Care Innovation Awards) were more likely to implement evidence-based models shown in the literature to improve care coordination and reduce readmissions. Participants often referred to grant funding which had enabled them to implement more costly TC strategies, though sustainability of those efforts was unpredictable. When funding and other resources were not readily available, communities implemented interventions that were more limited in scope or had less intensive resource requirements.Many of the barriers to transitional care implementation were described as the absence of the facilitators above. For example, lack of resources was identified by 10 of the 16 groups of providers as confounding collaborative TC programs, as illustrated by one participant, “[funding is]” just not adequate and continues to not be adequate.” Nuances of perspectives around funding concerns are further detailed in the section below discussing differences among provider types and communities.Previous study of coalitions as permissive collaboration structures for improved care have been observational only, noting associations between such structures and lower hospitalization utilization rates.25,26,32 To our knowledge, there are no formal studies of coalition building techniques, structures or membership that illuminate best methods for promoting effective TC model implementation, and especially for models that extend care into non-medical home-based support. Additionally, the perspectives of non-medical home support staff around barriers and facilitators to effective participation in care transitions interventions seems understudied. This is an important and timely priority as there is now broad recognition of the impacts of social determinants of health on healthcare spending and utilization33 and governmental focus on advancing equity.34Our findings also highlighted that TC efforts should be well integrated within the organization as well as within the community. Such integration includes selecting the most appropriate intervention to address root causes of readmissions, implementing the intervention across settings, and ensuring that evaluation and monitoring informs a process of continuous improvement to increase the likelihood of success. While implementing a proven model to improve care transitions is ideal, in our sample, the implementation of TC efforts vary based on available resources, community demographics, and inter-agency collaboration. Specifically, those communities with funding from community-based care transitions programs or other external sources were more likely to implement evidence-based transitional care models (e.g., Project RED, Project BOOST, Transitional Care Model) in their entirety, while others relying on institutional support were typically implementing strategies very specific to identified problems (e.g., population characteristics). Regardless of the interventions selected, or the funding underlying ongoing processes, uniformly participants felt their interventions and dedication to them were limited by absence of guaranteed ongoing funding and/or resources. Sustainment is an ongoing challenge. While organization needs process change to sustain intervention impact and community needs collaborative financial and operation models to improve TC, health care payment models need to reimburse care coordination and management services for sustained community health.Our study had limitations that should be considered when interpreting our results. First, our recruitment efforts focused on providers actively engaged in care transitions work, despite efforts to recruit from a variety of regions and contexts, our sample was not representative of all providers. The composition of group interviews also varied, with some having participation from representatives of nearly all coalition organizations, but others with a smaller group with more limited representation. However, based on our analysis, the common barriers and facilitators in implementing TC efforts are similar among different healthcare organizations, regardless of ownership, therefore, we are confident that our findings are generalizable. Second, our interviews also took place well into the implementation process, which could also have impacted our findings, as many providers may have encountered conflicting beliefs about local causes of readmissions early in the collaborative process, but the work has softened the memory of these differences. Third, while we interviewed 63 individual providers, many were from the same community and involved in the same work. Due to our sampling methodology and interview process, we could not address which specific barriers most hindered adoption of which specific TC strategies, nor could we establish which strategies were most likely to be adapted and in which environments. We were also unable to stratify our findings by provider type. Fourth, we allowed providers to choose a group or individual interview format. While group interviews allowed for more interactive discussion, they were not best for eliciting more sensitive information related to relationships and challenges; the possibility remains that some individuals did not fully express themselves. Finally, the interviews for this study took place in 2015. Despite this significant time interval, there has been little effort in addition to what is described in this paper to improve transitional care through community collaboration. The CCTP program ended, and community-based work facilitated by the CMS QIN-QIO program continues, with a focus on other improvement areas in addition to readmissions reduction. Therefore, we still consider our findings to be currently relevant. Despite these limitations, our study provided an in-depth understanding of how TC implementation is facilitated, supported and adapted in a variety of contexts.

Publisher Copyright:
© 2022


  • Care coordination
  • Care transitions
  • Community coalitions
  • Provider collaboration
  • Readmissions

ASJC Scopus subject areas

  • Health Policy


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