Which transitions count? A systematic hermeneutic review of the literature on transitions of care

Introduction: Transitions of care are defined as critical moments along the care continuum for patients as they navigate changes in their health status or level of care. As a result, transitions of care have been a key focus of policies and targeted interventions, including the emergence of health policies aimed at moving “care closer to home” (NHS England, 2014), with the goal of increasing the integration of acute and primary care settings and minimizing transitions of care. Nevertheless, researchers suggest that existing research on transitions of care is largely descriptive and lacks theoretical depth, which limits its applicability to different clinical contexts (Geary & Schumacher, 2012).

Aim: We therefore aim to review the existing literature and theoretical frameworks on transitions of care, with a focus on primary care settings.

Methods: We undertook a systematic hermeneutic review—an approach that emphasizes analytical reading, including identifying key concepts and building interpretations across a large and heterogeneous body of literature. Our initial search yielded 1,640 articles, and we included 54 sources in our review.

Results: We identified five narratives concerning transitions of care: 1) the emphasis of acute settings, 2) transitions of care as disruptive, 3) the push and desire for increased standardization, 4) transitions of care as intermediate, and 5) transitions of care as assessment tools.

Despite interdisciplinary discussions, the main narratives of transitions of care centered around hospitals, with limited consideration for transitions in community settings. Moreover, using re-hospitalization admission rates as the primary metric to measure the effectiveness of care transitions initiatives fails to capture the negotiations required by patients and staff. This highlights the undercurrent of a positivist and biomedical approach, as well as the influence of broader health policy in shaping the methods and narratives used to define transitions.

Conclusion: We consider this gap pertinent, given the increasing complexity of care delivered in community settings through remote chronic care models. While the use of re-hospitalization admission rates as the primary metric for transitions of care fails to capture the sense-making applied in navigating transitions, it highlights the influence of broader policy in shaping the methods and narratives used in defining transitions. We consider the misalignment between the discourse surrounding transitions of care and shifts in care delivery to be pertinent, as current metrics are unprepared for the increased shift to community-based care or neighborhood-level care.

Moreover, these current metrics fail to capture and contend with evolving transitions of care and how both patient, care, and staff experiences are shaped by them. In response, we suggest further engagement with theory to deconstruct our attention from settings and re-conceptualize transitions of care as marked also by changes in practices, materials, and people.