Healthcare Providers’ Perspectives on Care Transitions for Adults with Complex Needs : A Qualitative Study

Background: Adults with complex health and social care needs (hereafter complex needs) frequently experience transitions across care settings that require coordination across multiple providers. Poorly managed transitions increase the risk of fragmented care, medication errors, and preventable harm. Persistent challenges include poor communication, unclear roles, and limited discharge plans.

 While existing evidence largely focuses on clinicians, care transitions involve a broader range of professionals whose experiences remain underexplored. This study examines healthcare providers’ experiences of care transitions for adults with complex needs across community, primary care, and hospital settings.

 

Approach. A descriptive qualitative study was conducted as part of a mixed-method research program across three sites in the provinces of Quebec and New Brunswick in Canada. Forty-six semi-structured interviews were conducted with a diverse range of healthcare professionals — including generalists, allied health professionals, specialists, and professionals working in community-based organizations and support programs — recruited through key informant sampling. Data were analyzed using inductive and deductive thematic approaches informed by a conceptual model of factors affecting care transitions.

 

 Results. Providers described interconnected challenges in care transitions at the patient, professional, and systemic levels. Socioeconomic vulnerability, housing instability, limited self-management, and patient decisions misaligned with clinical recommendations, complicated safe transitions, often forcing providers to balance patient autonomy with risk management. At the professional level, fragmented communication, lack of relational continuity with patients, informal coordination, insufficient planning, limited recognition of the expertise of certain professionals in community organizations, and restricted influence over care trajectories hindered care transitions. These issues point to the importance of clarifying professional roles and establishing well-defined processes for responsibility transfers across settings and actors. Systemic constraints, such as rigid eligibility criteria to access care programs and services, service saturation, and weak integration of external organizations and community partners, further limited responsiveness and contributed to structural inequities in care transitions.

 

 Providers often reported limited agency and feelings of powerlessness in addressing these issues, leading them to resort to solutions misaligned with patient needs. These factors collectively challenge the coordination and quality of care transitions for adults with complex needs. Implications.

 

This study highlights how care transitions are shaped by interrelated factors at patient, professional, and systemic levels. Improving transitions requires not only better clinical coordination, but also attention to lived realities, professional agencies, and structural constraints. Strengthening cross-sector collaboration, clarifying roles, and embedding flexibility can foster safer, more equitable transitions for adults with complex needs.