Clinicians' views on improving inter-organizational care transitions

Area of Science:

• Healthcare Management
• Patient Care Coordination
• Health Services Research

Background:

• Complex health conditions necessitate multi-provider care, increasing vulnerability during healthcare setting transitions.
• Poorly managed care transitions lead to adverse patient outcomes and increased healthcare costs.
• Limited understanding exists regarding care transitions from acute care to complex continuing care and rehabilitation settings.

Purpose of the Study:

• To explore clinicians' perceptions of strategies for improving patient care transitions.
• To identify key factors influencing the quality of inter-organizational transfers from acute care to complex continuing care and rehabilitation.

Main Methods:

• A qualitative study employing semi-structured interviews with clinicians.
• Interviews conducted with 31 clinicians at an acute care hospital and a complex continuing care/rehabilitation organization.
• Content analysis of interview transcripts using a coding schema.

Main Results:

• Three emergent themes identified strategies for quality inter-organizational patient transitions.
• Theme 1: Enhanced inter-clinician communication.
• Theme 2: Vigilance regarding patient transfer readiness and care needs.
• Theme 3: Accurate and complete documentation in patient transfer records.

Conclusions:

• Clinician insights highlight the need for collaborative approaches to inter-organizational care transitions.
• Augmenting written transfer records with verbal reports is crucial for effective patient status and care plan discussions.
• Future research should focus on designing and testing interventions to optimize care transitions and feedback loops for complex patients.