UNDERSTANDING FACILITATORS AND BARRIERS TO CARE TRANSITIONS: HEALTH SYSTEM AND COMMUNITY PARTNER PERSPECTIVES. (11th November 2018) - Hirschman, K B
Abstract: Care transitions between and across settings are often fragmented and place older adults at high risk for poor outcomes. Finding ways to improve care transitions for patients and their family caregivers across the continuum of settings is necessary. Therefore, we conducted site visits across the United States at 45 health care organizations—community hospitals, academic medical centers, integrated health systems, and broader community partnerships—using a combination of qualitative techniques—including observation, document review, and semi-structured interviews. Over 1, 000 participants representing management and leadership, transitional care team members, internal stakeholders, community partners, patients, and family caregivers participated. Common facilitators of effective care transitions included: strong collaboration within and beyond the organization, staff buy-in, and patient and family centered care.