How Do Care Transitions Work?: Unraveling the Working Mechanisms of Care Transition Interventions

Abstract

Background: Failure of safe care transitions after hospital discharge results in unnecessary worsening of symptoms, extended period of illness or readmission to the hospital. Objective: The objective of this study was to add to the understanding of the working of care transition interventions between hospital and home through unraveling the contextual elements and mechanisms that may have played a role in the success of these interventions, and by developing a conceptual model of how these components relate to each other. Research Design: This was a qualitative study using in-person, semi-structured interviews, based on realist evaluation methods. Subjects: A total of 26 researchers, designers, administrators, and/or practitioners of both current "leading" care transitions interventions and of less successful care transition intervention studies or practices. Measures: The contextual elements and working mechanisms of the different care transition intervention studies or practices. Results: Three main contextual factors (internal environment, external environment, and patient population) and 7 working mechanisms (simplifiying, verifiying, connecting, translating, coaching, monitoring, and anticipating) were found to be relevant to the outcome of care transition interventions. Context, Intervention, Mechanism, and Outcome (CIMO) configurations revealed that, in response to these contextual factors, care transition interventions triggered one or several of the mechanisms, in turn generating outcomes, including a safer care transition. Conclusion: We developed a conceptual model which explains the working of care transition interventions within different contexts, and believe it can help support future successful implementation of care transition interventions.