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

Area of Science:

• Health Services Research
• Patient Experience
• Complex Care Management

Background:

• Individuals with multimorbidity face complex health and social care needs, often experiencing fragmented care during transitions between settings.
• Care transitions are critical junctures that significantly influence patient outcomes and experiences, yet associated factors are poorly understood.
• Frequent transitions across home, community, primary care, and hospital settings increase the risk of care fragmentation for patients with complex needs.

Purpose of the Study:

• To identify individual and environmental factors associated with positive or negative care transition experiences.
• To understand the relationship between patient complexity, self-management, and transition outcomes.
• To explore how different healthcare settings influence patient experiences during care transitions.

Main Methods:

• Prospective correlational design with participants recruited from emergency departments.
• Inclusion criteria: ≥3 ED visits/year, positive CONECT-6 screen, IMSA score ≥19.
• Data collected on sociodemographic, clinical, psychosocial, and environmental variables; transition experiences measured at six months using PEICS-adapted scale; multivariable linear regression used for analysis.

Main Results:

• Biopsychosocial complexity, self-management capacity, and recruitment site significantly influenced transition experiences.
• Higher biopsychosocial complexity correlated with less favorable transition experiences.
• Greater self-management capacity was associated with more positive care transition experiences.

Conclusions:

• Care transition experiences are significantly linked to patients' biopsychosocial complexity and self-management abilities.
• Site-level variations indicate the substantial impact of organizational and systemic factors on transition experiences.
• Further research is essential to elucidate how organizational and systemic factors shape care transitions for individuals with complex needs.