Factors associated with care transition experiences among individuals with complex needs: A prospective study

Individuals with multimorbidity often have complex health and social care needs and experience frequent transitions across various settings and providers, including home, community services, primary care, and hospitals. These transitions represent pivotal moments within their care trajectories, where the risk of care fragmentation is significantly increased. Although these transitions play an important role in shaping patient experiences and outcomes, the factors associated with them remain insufficiently documented.

This study aimed to identify individual and environmental factors associated with either positive or negative experiences of care transition among individuals with complex needs.

Using a prospective correlational design, participants were recruited from emergency departments at three sites in two Canadian provinces. Eligible individuals had ≥3 ED visits in the past year, screened positive on the COmplex NEeds Case-finding Tool-6 (CONECT-6), and had complex needs confirmed by an INTERMED Self-Assessment (IMSA) score of 19 or higher. Baseline data included sociodemographic, clinical, and psychosocial variables; environmental variables were derived from geocoded postal codes. At six months, participants completed a 12-item scale on care transitions adapted from the Patient Experience of Integrated Care Scale (PEICS). Multivariable linear regression identified factors associated with transition experiences.

Of 292 participants recruited, 167 completed the follow-up. Biopsychosocial complexity, self-management capacity, and recruitment site were significantly associated with transition experiences. Higher complexity was associated with less favorable experiences, while stronger self-management was linked to more positive transitions.

Care transition experiences are associated with biopsychosocial complexity and self-management abilities, with site-level differences point to organizational and systemic influences. Further research is needed to examine how organizational and system-level factors shape transition experiences for individuals with complex needs.