Abstract
Introduction: One of the ongoing challenges in health care is ensuring patients/families and also health care providers have clear direction and implementation guidance around transitions in care across all care and community settings that includes integration, continuity and coordination. Clearly understanding patient and care provider experiences including what works and where improvements are needed with care transitions across acute and community settings has been an ongoing challenge for most health care systems before COVID-19. During COVID-19, efforts to identify and use experience measures were complicated and impacted because of rapidly enforced restrictions and guidelines for patient/client, family and provider safety.
Aims, Objectives and Methods: Exploring the experiences of patients/clients, families and care providers with their care transitions between acute and community-based care settings prior to and during COVID-19, along with changes in care outcomes, practices, policies and services became the focus of a two-year pilot study in one Canadian provincial health system. We co-designed relevant acute to community care transition process and outcome/impact experience indicators/measures with patients/clients, families and care providers; and explored the feasibility for transferring measures and lessons learned for practice, policy and service changes as part of follow-up and post COVID new ‘norm’ transformation of care transitions.
Results: The study involved the Provincial Seniors and Continuing Care Advisory Council, Continuing Care Quality Committee and eight pilot sites involving care transitions from acute to community settings within the provincial health system. Each care setting involved patient/family advisors co-designing and implementing the initiative with care providers, including survey development, and gathering, analyzing and interpreting client/patient and care provider experiences. Findings in each and across settings included identifying common core patient/family and care provider experience indicators/measures regarding acute to community care transitions, before and during COVID. Themes for what makes transitions in care successful from pre to during COVID were also confirmed – e.g. clear communication, navigation and information/direction for all stakeholders. The aggregated findings targeted health outcomes and guided changes in transition practices from across acute points of care including Emergency and care units, to various community-based care settings including Home Care, Long-term or other interim programs– e.g. CHOICE programs.
Conclusions: Understanding the experiences of patients/clients, families and care providers regarding care transitions between acute and community-based settings are essential to understanding what works well and where there are gaps in the system leading to failed or unsatisfactory patient transitions across care settings. Such findings guide quality and safety improvement.
Implications: Identified transition core measures continue to be studied for transferability across acute to community care settings. As well, COVID-19 impacts on practice, policy and service changes involving care integration and specifically transitions, need to be monitored for how well care settings adapt to “new norms” and meet patient/client needs.