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 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. Yet there are currently several mechanisms in the real-world practice that impede the successful implementation of TCIs. In a recent study, Assistant Professor Amal Fakha (FEB’s Department of Innovation management & Strategy) and co-authors thus developed a novel set of implementation strategies.

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. The six core components for transitional care that can be identified are patient engagement, caregiver engagement, patient education, caregiver education, complexity management, and care continuity.

Care continuity is an extensive core component that prevails in the majority of TCIs. Hence, it is a backbone component specific to these innovations, given their nature to organize the continuum of care for older persons across different settings. To ensure this care continuity, 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, not just medically, but also socially or psychologically. 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.

Organizational challenges

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.

Implementation strategies

To support practitioners in the field, Amal Fakha and co-authors Bram de Boer, Jan P. Hamers, Hilde Verbeek and Theo van Achterberg developed a novel set of implementation strategies carefully selected for TCIs. Fakha: “Initially, our findings identified 20 TCIs whereby the majority aimed to improve care transitions and had care continuity, including the presence of staff with a transition role, as a fundamental component. Consequently, we determined 12 priority factors, mainly linked to the organizational setting, which influence the implementation of TCIs and hence require specific strategies to address them. This culminated in the formulation of a set of various implementation strategies at the organizational, individual, policy, and innovation levels. The majority of strategies were at the organizational level and are supported by evidence demonstrating their positive impact on implementing change. The strategy ‘organizational diagnosis and feedback’, for example, assesses organizational aspects that should be in place and the organization’s readiness to implement a TCI. Facilitating and creating a supportive organizational environment proved an effective strategy to improve the adoption and implementation of new guidelines in clinical settings. Likewise, using communication systems including health information technology (HIT) to improve information continuity among providers within and across care organizations improved adherence to new guidelines in a nursing home.”

Fakha and co-authors emphasize that the use of implementation strategies is a focal task in the prospective implementation of any TCI in practice. “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 implementing a TCI. Each strategy within our proposed set includes practical applications outlining how the strategy should be applied in real practice by implementers of TCIs across diverse healthcare settings. Additionally, we recommend a further tailoring of these strategies, to align them 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.”

Questions? Please contact Amal Fakha.

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