Crossing the Communication Chasm: Challenges and Opportunities in Transitions of Care from the Hospital to the Primary Care Clinic

Rattray, Nicholas A.; Sico, Jason J.; Cox, LeeAnn M.; Russ, Alissa L.; Matthias, Marianne S.; Frankel, Richard M.

doi:10.1016/j.jcjq.2016.11.007

Cited by 24 publications

(43 citation statements)

References 47 publications

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“…This calls for procedures to improve integration both within and across healthcare organizations. Enabling multiple modes of communication, such as face-to-face communication and agreement about guidelines and treatment plans have been identified as facilitators for effective transitions [40]. Technology, such as video-communication tools could be used to facilitate cross-organizational communication and learning [41].…”

Section: Discussionmentioning

confidence: 99%

Perceptive Dialogue for Linking Stakeholders and Units During Care Transitions – A Qualitative Study of People with Stroke, Significant Others and Healthcare Professionals in Sweden

et al. 2020

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Introduction: Care transitions are a complex set of actions that risk poor quality outcomes for patients and their significant others. This study explored the transition process between hospital and continued rehabilitation in the home. The process is explored from the perspectives of people with stroke, significant others and healthcare professionals in Stockholm, Sweden. Method: Focus group interviews (n = 10), semi-structured individual interviews (n = 23) and interviews in dyad (n = 4) were conducted with healthcare professionals, people with stroke and significant others, altogether 71 participants. Data was collected and analyzed using Grounded Theory. Results: One core category "Perceptive dialogue for a coordinated transition", and two categories "Synthesis of parallel processes for common understanding" and "The forced transformation from passive attendant to uninformed agent" emerged from the analysis. The transition consisted of several parallel processes which made it difficult for the stakeholders to get a common understanding of the transition as a whole. Enabling a perceptive dialogue was as a prerequisite for the creation of a common understanding of the care transition. Conclusion: This study elucidates that a perceptive dialogue with patients/significant others as well as within and across organizations is part of a coordinated and person-centred transition. There is an extensive need for increased involvement of patients and significant others regarding dialogue about health conditions, procedures at the hospital and preparation for self-management after discharge.

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Section: Discussionmentioning

confidence: 99%

Perceptive Dialogue for Linking Stakeholders and Units During Care Transitions – A Qualitative Study of People with Stroke, Significant Others and Healthcare Professionals in Sweden

et al. 2020

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“…hospital management [28]), specific aspects of transitional care (e.g. day of discharge [38] or communication [39]), and/or specific patient groups (e.g. heart failure [28] or stroke [39]), this study gathers multidisciplinary staff perspectives across a variety of healthcare contexts.…”

Section: Introductionmentioning

confidence: 99%

“…day of discharge [38] or communication [39]), and/or specific patient groups (e.g. heart failure [28] or stroke [39]), this study gathers multidisciplinary staff perspectives across a variety of healthcare contexts. We sought to understand what facilitates successful transitions of care within high performing teams, and the ways in which staff overcome the challenges faced in their everyday work.…”

Section: Introductionmentioning

confidence: 99%

Delivering exceptionally safe transitions of care to older people: a qualitative study of multidisciplinary staff perspectives

Baxter¹,

Shannon²,

Murray³

et al. 2020

BMC Health Serv Res

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Background: Transitions of care are often risky, particularly for older people, and shorter hospital stays mean that patients can go home with ongoing care needs. Most previous research has focused on fundamental system flaws, however, care generally goes right far more often than it goes wrong. We explored staff perceptions of how high performing general practice and hospital specialty teams deliver safe transitional care to older people as they transition from hospital to home. Methods: We conducted a qualitative study in six general practices and four hospital specialties that demonstrated exceptionally low or reducing readmission rates over time. Data were also collected across four community teams that worked into or with these high-performing teams. In total, 157 multidisciplinary staff participated in semistructured focus groups or interviews and 9 meetings relating to discharge were observed. A pen portrait approach was used to explore how teams across a variety of different contexts support successful transitions and overcome challenges faced in their daily roles. Results: Across healthcare contexts, staff perceived three key themes to facilitate safe transitions of care: knowing the patient, knowing each other, and bridging gaps in the system. Transitions appeared to be safest when all three themes were in place. However, staff faced various challenges in doing these three things particularly when crossing boundaries between settings. Due to pressures and constraints, staff generally felt they were only able to attempt to overcome these challenges when delivering care to patients with particularly complex transitional care needs. Conclusions: It is hypothesised that exceptionally safe transitions of care may be delivered to patients who have particularly complex health and/or social care needs. In these situations, staff attempt to know the patient, they exploit existing relationships across care settings, and act to bridge gaps in the system. Systematically reinforcing such enablers may improve the delivery of safe transitional care to a wider range of patients. Trial registration: The study was registered on the UK Clinical Research Network Study Portfolio (references 35272 and 36174).

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“…Respondents eagerly offered ideas for improvement, many of which were aligned with recommendations from investigators focused on SNF care (6, 7, 12, 28, 30, 32, 33). These included a time-out at discharge to allow providers to complete transfer tasks and documentation without interruption, use of a throughput nurse to manage discharges, and tighter integration of social work into the general medicine service to better address patient care needs.…”

Section: Discussionmentioning

confidence: 99%

Care Transitions Between Hospitals and Skilled Nursing Facilities: Perspectives of Sending and Receiving Providers

Britton¹,

Ouellet²,

Minges³

et al. 2017

The Joint Commission Journal on Quality and Patient Safety

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Background One in four Medicare patients hospitalized for acute medical illness is discharged to a skilled nursing facility (SNF); 23% of these patients are readmitted to the hospital within 30 days. The care transition from hospital to SNF is often marked by disruptions in care and poor communication among hospital and SNF providers. A study was conducted to identify the perspectives of sending and receiving providers regarding care transitions between the hospital and the SNF. Methods Hospital (N = 25) and SNF providers (N = 16) participated in qualitative interviews assessing patient transfers and experiences with unplanned hospital readmissions. Data were analyzed by a multidisciplinary coding team using the constant comparison method. Results Four main themes emerged: increasing patient complexity, identifying an optimal care setting, rising financial pressure, and barriers to effective communication. The data highlighted hospital and SNF providers’ shared concerns about patient-level risk factors and escalating costs of care. It also identified issues that separate hospital and SNF providers, including different access to resources and information. Conclusions Hospital and SNF providers are challenged to meet the needs of complex patients. They are asked to establish comprehensive care plans for patients with significant medical and psychosocial issues while navigating tense relationships between healthcare institutions and rising financial pressures. The concerns of both hospital and SNF providers must be considered in order to develop practices that can improve the quality, cost, and safety of care transitions.

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Crossing the Communication Chasm: Challenges and Opportunities in Transitions of Care from the Hospital to the Primary Care Clinic

Cited by 24 publications

References 47 publications

Perceptive Dialogue for Linking Stakeholders and Units During Care Transitions – A Qualitative Study of People with Stroke, Significant Others and Healthcare Professionals in Sweden

Perceptive Dialogue for Linking Stakeholders and Units During Care Transitions – A Qualitative Study of People with Stroke, Significant Others and Healthcare Professionals in Sweden

Delivering exceptionally safe transitions of care to older people: a qualitative study of multidisciplinary staff perspectives

Care Transitions Between Hospitals and Skilled Nursing Facilities: Perspectives of Sending and Receiving Providers

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