Article Title

Implementing a Transitional Care Program for Older Adults at High Risk for Readmission

Publication Date



transitional care, qualitative research


Background/Aims: This study describes the implementation of a transitional care program for older adults at high risk for hospital readmission. Despite increasing efforts to reduce preventable readmissions through postdischarge care coordination, little research has been done on how to operationalize transitional care in community settings. We sought to understand how implementation efforts were impacted by factors including intervention complexity, patient beliefs about transitional care, and program fidelity with ramifications on staff roles and scope of work.

Methods: Our analysis is guided by the Agency for Healthcare Research and Quality “Care Transitions Framework” (CTF), a novel adaptation of the Consolidated Framework for Implementation Research. Seventeen in-depth interviews with program staff and leadership were conducted in January and February 2014. Interviews were recorded, transcribed verbatim and analyzed by two qualitative researchers for intercoder reliability based on emergent themes and relevant constructs from the CTF.

Results: The intervention was a complex collaboration between organizations, which served to bridge multiple settings ranging from the hospital and outpatient clinic to the patient’s home and community. While this partnership allowed for comprehensive services across the care continuum, it posed unique operational challenges for program coordination and communication. Challenges included engaging hospital staff to fully understand the program’s goals and scope of services, particularly when making referrals. Patients’ knowledge and beliefs about transitional care services also directly impacted their choice to enroll, as many older patients have preconceived notions about receiving home-based assistance and what that signifies, despite the potential benefits of such services. Finally, fidelity to the program’s original coaching model was affected by midstream modifications to patient eligibility criteria. As the program was spread to other hospital units, patients with more complex medical and social needs were enrolled, resulting in increasing shifts from health coaching to clinical case management. This, in turn, created greater need for clarity around the referral process as well as staff roles and scope of work.

Discussion: This study describes contextual factors that impacted the implementation and hospitalwide spread of a transitional care program for older adults. Lessons learned can inform future efforts to implement similar transitional care interventions that are based in the community.




April 6th, 2015


April 28th, 2015