Factors related to care transitions experience among individuals with complex needs: A multi-site prospective correlational study

Background: Individuals with complex health and social care needs often experience multiple care transitions across home, community, primary care, and hospital settings. These transitions create care fragmentation that compromises safety, autonomy, and overall wellbeing. This study aimed to identify individual and environmental factors associated with positive or negative care transition experiences among individuals with complex needs.

 

Approach: A prospective correlational study was conducted across three sites in two Canadian provinces. Adults with ≥3 emergency department (ED) visits in the previous year were screened using the COmplex NEeds Case-finding Tool – 6 (CONECT-6). Those screening positive completed the INTERMED Self-Assessment (IMSA) to confirm complex needs. At baseline, participants completed validated questionnaires assessing sociodemographic, clinical, and psychosocial variables. Environmental variables were derived from geocoded postal codes, using national databases.

 

 Six months later, care transition experiences were assessed using a 12-item scale adapted from the Patient Experience of Integrated Care Scale (PEICS). Results: Of the 292 participants enrolled, 167 completed the six-month follow-up. The distribution of the care transition experience (dependent variable) had a mean of 30.71 (SD = 10.30) out of 52, with scores ranging from 2 to 48. Care transition experiences were significantly associated with biopsychosocial complexity, self-management capacity, and recruitment site. Participants with higher biopsychosocial complexity reported poorer experiences, whereas stronger self-management skills predicted more positive transitions.

 

Implications: These findings emphasize that both individual complexity and self-management capabilities influence care transition experience. The observed differences between recruitment sites further suggest that organizational and systemic factors also play a role. The final regression model explained 16.6% of variance in care transition experiences, highlighting the need for further research on structural and contextual factors. Future research is warranted to more thoroughly investigate how organizational and systemic factors might better support individuals with complex needs as they navigate transitions across various care settings. For international delegates, this research offers insights into designing inclusive and integrated care models that are responsive to the realities of vulnerable populations such as individuals with complex health and social care needs