Understanding Facilitators and Barriers to Care Transitions: Insights from Project ACHIEVE Site Visits

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Background Care transitions between clinicians or settings are often fragmented and marked by adverse events. To increase patient safety and deliver more efficient and effective health care, new ways to optimize these transitions need to be identified. A study was conducted to delineate facilitators and barriers to implementation of transitional care services at health systems that may have been adopted or adapted from published evidence-based models. Methods From March 2015 through December 2015, site visits were conducted across the United States at 22 health care organizations—community hospitals, academic medical centers, integrated health systems, and broader community partnerships. At each site, direct observation and document review were conducted, as were semistructured interviews with a total of 810 participants (5 to 57 participants per site) representing various stakeholder groups, including management and leadership, transitional care team members, internal stakeholders, community partners, patients, and family caregivers. Results Facilitators of effective care transitions included collaborating within and beyond the organization, tailoring care to patients and caregivers, and generating buy-in among staff. Commonly reported barriers included poor integration of transitional care services, unmet patient or caregiver needs, underutilized services, and lack of physician buy-in. Conclusion True community partnership, high-quality communication, patient and family engagement, and ongoing evaluation and adaptation of transitional care strategies are ultimately needed to facilitate effective care transitions. Health care organizations can strategically prioritize transitional care service delivery through staffing decisions, by making transitional care part of the organization's formal board agenda, and by incentivizing excellence in providing transitional care services.

Original languageEnglish
Pages (from-to)433-447
Number of pages15
JournalJoint Commission Journal on Quality and Patient Safety
Issue number9
StatePublished - Sep 2017

Bibliographical note

Funding Information:
The present study provides important insight into how health care organizations can lead effective implementation. Specifically, we found that the facilitators of and the barriers to effective transitional care were fairly consistent across sites, suggesting that the strategies that have proven effective in improving services at some sites may likely prove successful in addressing similar issues at other sites. Improving transitional care services is a complex challenge that requires clear structure and flexibility, committed leadership and engaged staff, and ongoing adaptation and evaluation of multiple implementation efforts. Many barriers to and facilitators of effective transitional care are structural in nature, and changing these deep-set patterns takes time, but identifying these structures represents a first step in addressing them. The barriers and facilitators identified in our analysis can and should be leveraged to develop true partnerships within a health organization and within the community beyond. Funding. This work was supported through a Patient-Centered Outcomes Research Institute (PCORI) award (Contract #TC-1403-14049 ). Disclaimer. All statements in this article, including its findings and conclusions, are solely those of the authors and do not necessarily represent the views of PCORI, its Board of Governors, or its Methodology Committee. Conflicts of Interest. All authors report no conflicts of interest. Allison M. Scott, PhD, is Associate Professor, Department of Communication, University of Kentucky, Lexington. Jing Li, MD, MS, is Assistant Professor of Internal Medicine and Administrative Director, Center for Health Services Research, University of Kentucky. Sholabomi Oyewole-Eletu, MD, formerly Research Assistant, Center for Health Services Research, University of Kentucky, is Resident in Internal Medicine, University at Buffalo, State University of New York. Huong Q. Nguyen, PhD, RN, is Research Scientist, Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California. Brianna Gass, MPH, is Manager, Quality Improvement, Telligen, Greenwood Village, Colorado. Karen B. Hirschman, PhD, MSW, is Research Associate Professor, and the NewCourtland Term Chair in Health Transitions Research, University of Pennsylvania School of Nursing, Philadelphia. Suzanne Mitchell, MD, MS, is Assistant Professor, Boston Medical Center, Boston. Sharon M. Hudson, PhD, is Assistant Professor, Research Pediatrics, Department of Pediatrics, Keck School of Medicine of USC, Los Angeles. Mark V. Williams, MD, is Professor and Vice Chair, Department of Internal Medicine; Director, Center for Health Services Research, University of Kentucky; and Member, Editorial Advisory Board, The Joint Commission Journal on Quality and Patient Safety .

Publisher Copyright:
© 2017 The Joint Commission

ASJC Scopus subject areas

  • Leadership and Management


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