“Imagine this scenario: an older person is moving from the hospital back home, yet the process is anything but smooth. They are feeling uncertain and confused about what awaits them post-hospital discharge.” Is there a way to improve this transition? This is where the transitional care innovations (TCIs) come into play. TCIs are innovations aimed at coordinating and streamlining the care continuity for patients, ensuring that they receive “the right care at the right time at the right place” as they move between multiple care settings during these transitions. For example, TCIs can be novel programs or models that improve the patient transfer from hospital to home or other settings by educating the patient on managing their health conditions and medications, organizing their follow-up care, or providing home support services. A central component of most TCIs is the presence of a transition care coach or manager that usually accompanies patients throughout their transition and provides them with the support they need and not just medical but also social or psychological. Obviously, TCIs are vital in meeting the diverse care needs of patients and enhancing their quality of life by making transitions as smooth as possible. However, despite clear benefits, the implementation of TCIs often encounters significant challenges in real-world practice.

A major issue is the need for tailored and evidence-based implementation strategies that address the wide array of contextual factors. Examples of such factors that mostly hinder the implementation process are lack of organizational resources, little to no organizational leadership commitment, minimal staff knowledge and skills, and absence of engagement of the key stakeholders within a healthcare system. Yet, the selection and use of implementation strategies specific for TCIs have remained largely undefined and minimal. Healthcare professionals often rely on past practices, by having in mind that “this has worked in the past,” “this is known to work,” “this seems promising,” or “this is how we have always done it” to implement a new TCI rather than evidence-based approaches. Unfortunately, this impedes the successful implementation of TCIs and hinders improving care transitions for patients.

To support practitioners in the field, we developed a novel set of implementation strategies. These new strategies target factors at the organizational, individual, policy, and innovation levels; and are supported by evidence demonstrating their positive impact on implementing change. For example, the strategy “organizational diagnosis and feedback” assesses organizational aspects that should be in place and the organization’s readiness to implement a TCI. Structural redesign maps the current inter-organizational interactions, work processes, and staff roles and identifies changes necessary to accommodate the implementation of a TCI.

Moving forward, it is imperative for future healthcare professionals to conduct a thorough analysis of their specific contexts and utilize this set of implementation strategies as a guiding roadmap for their implementation endeavors. Each strategy within this set is proposed with practical applications outlining how it should be applied in real practice by implementers of TCIs across diverse healthcare settings. Additionally, a further tailoring of these strategies is recommended to align with the unique characteristics of different healthcare systems in various countries. Hence, in continuing to harness the power of implementation science research, we move closer to a future where seamless care transitions become the norm, rather than the exception. 

Author: Amal Fakha - a.fakha@rug.nl

Reference:

Fakha, A., de Boer, B., Hamers, J.P., Verbeek, H., van Achterberg, T. Systematic development of a set of implementation strategies for transitional care innovations in long-term care. Implement Sci Commun 4, 103 (2023). https://doi.org/10.1186/s43058-023-00487-3