Communication and coordination processes supporting integrated transitional care: Australian healthcare practitioners’ perspectivesQuality and Patient Safety
Identifying strengths and weaknesses in transitional care for older adults in an Australian setting.
Although a large body of research has identified effective models of transitional care, questions remain about the optimal translation of this knowledge into practice. In Australia, the introduction of a model of consumer-directed care uniquely challenges the practice of integrated care transitions for older adults. This study aimed to identify strengths and weaknesses in transitional care for older adults in an Australian setting by describing healthcare practitioners’ experiences of care provision.
Transitional care is referred to as continuous and unified care for patients across different health programs and settings . Communication, care coordination, medication reconciliation, functional improvement and self-management are important features of transitional care [1, 2]. In accordance with contemporary research [1, 3, 4, 5], we focussed on communication and care coordination as essential processes in clinical care that support care integration during older adults’ care transitions.
Previous studies have found that compared with usual care, formal transitional care interventions including discharge assessment, planning, care coordination, communication, medication reconciliation, and self-management reduce length of stay and re-admission rates, and improve patient satisfaction with care [5, 6]. Two well-researched US-based models of care, the Care Transitions Intervention  and the Transitional Care Model  have been influential in re-orienting health services towards the importance of self-management and advanced practice nursing support. Other studies of transitional care have explored care integrated with multidisciplinary teams and aged care teams and found reduced readmission rates and reduced functional decline in older adults [7, 8].
This study aimed to identify implementation strengths and weaknesses in integrated transitional care for older adults in an Australian setting by describing how healthcare practitioners experience care provision across acute, sub-acute and community care programs. Data was collected in two phases using interviews and focus groups. Participants in phase one interviews included multidisciplinary practitioners working across acute, sub-acute and community settings. Phase two focus groups were conducted to confirm the findings in phase one. Participants included healthcare practitioners with a key role in transitional care and patients and carers involved in transitional care. Phase one of the study identified four key themes including: (1) rapid and safe care transition, (2) discussing as a team, (3) questioning the discharge, and (4) engaging patients and carers and these were endorsed by participants involved in the phase 2 focus groups.
The findings highlight the need for health practitioners to adapt their care coordination and communication practice to an evolving care context of stronger expectations that older adults and their informal carers will take greater responsibility for their own care in the community. In care transition contexts shaped by multidisciplinary teams, sub-acute care and consumer-directed care, health practitioners should focus on supporting older adults and their informal caregivers to navigate their own care transitions. To improve care integration during older adults’ care transitions, health services organisations and planners should adapt systems to support health practitioners in assessment of patients’ self-care abilities regarding negotiation and navigation of their own care transitions.
1: Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial [corrected] [published erratum appears in J AM GERIATR SOC, 2004 Jul; 52(7): 1228]. Journal of the American Geriatrics Society, 2004; 52(5): 675–84. PubMed PMID: 2004190038. DOI: https://doi.org/10.1111/j.1532-5415.2004.52202.x
2: Coleman EA, Parry C, Chalmers S, Min S. The care transitions intervention: Results of a randomized controlled trial. Arch Intern Med, 2006; 166. DOI: https://doi.org/10.1001/archinte.166.17.1822
3: Bellon J, Bilderback A, Ahuja-Yende N, Wilson C, Altieri Dunn S, Brodine D, et al. University of Pittsburgh Medical Centre Home Transitions Multidisciplinary Care Coordination reduces readmissions for older adults. Journal of the American Geriatrics Society, 2019; 67: 156–63. DOI: https://doi.org/10.1111/jgs.15643
4: Cameron A, Lart R, Bostock L, Coomber C. Factors that promote and hinder joint and integrated working between health and social care services: A review of research literature. Health & Social Care In The Community, 2014; 22(3): 225–33. PubMed PMID: 23750908. DOI: https://doi.org/10.1111/hsc.12057
5: Allen J, Hutchinson AM, Brown R, Livingston PM. Quality care outcomes following transitional care interventions for older people from hospital to home: A systematic review. BMC Health Services Research, 2014; 14: 1–27. DOI: https://doi.org/10.1186/1472-6963-14-346
6: Goncalves-Bradely C, Lannin NA, Clemson LM, Cameron I, Shepperd S. Discharge planning from hospital. London: Cochrane Collaboration; 2016. DOI: https://doi.org/10.1002/14651858.CD000313.pub5
7: Hickman LD, Phillips JL, Newton PJ, Halcomb EJ, Al Abed N, Davidson PM. Multidisciplinary team interventions to optimise health outcomes for older people in acute care settings: A systematic review. Archives Of Gerontology And Geriatrics, 2015; 61(3): 322–9. PubMed PMID: 26255065. DOI: https://doi.org/10.1016/j.archger.2015.06.021
8: Legrain S, Tubach F, Bonnet-Zamponi D, Lemaire A, Aquino JP, Paillaud E, et al. A New Multimodal Geriatric Discharge-Planning Intervention to Prevent Emergency Visits and Rehospitalizations of Older Adults: The Optimization of Medication in AGEd Multicenter Randomized Controlled Trial. Journal of the American Geriatrics Society, 2011; 59(11): 2017–28. PubMed PMID: 2011365955. DOI: https://doi.org/10.1111/j.1532-5415.2011.03628.x