Advancing a Transitions in Care Guideline: Reflections on Strategies to Engage Staff

Background: Alberta Health Services (AHS) Primary Health Care Integration Network (PHCIN) led the development and implementation of the Home to Hospital to Home (H2H2H) Transitions Guideline over several years. Various enhanced operational practices are being trialed to improve patient care. In particular, H2H2H supported information organization and timely transfer of information between acute and primary care (PC), developed a patient discharge guide, and identified recommended practices for follow-up in primary care. PC has a significant role to play in improving transitions in care (TiC) practices to support patients transitioning from acute care back into the community.The ADAPT study was designed to support PC in enhancing their practices through the co-design and implementation of recommended practices from the H2H2H Guideline. ADAPT focuses on patient groups that are known to experience higher risks for adverse events when discharged from acute care (i.e., heart failure, COPD, cirrhosis, and end-stage kidney disease). ADAPT is applying implementation and improvement sciences approaches to guide the work to understand how PC providers and teams support patients as they transition from acute care back to their community, and to co-design practice changes that address gaps and/or challenges to enhance patient support. Additionally, ADAPT brings standardized evidence informed interventions to PC that can be tailored to the PC team context to support sustainable changes. Approach: Prior to enrolling PC teams into the ADAPT study, 7 interviews were conducted with PC providers and team members to understand current practices used from the time patients with medical complexities were admitted to acute care to the time they were followed up post-discharge. Results from these interviews indicated substantial variability in activities and resources dedicated to acute care follow-up activities, as well as timely and comprehensive information sharing between acute care and primary care.We are applying the Interactive Systems and Quality Implementation Frameworks to identify key steps within implementation phases and inform how roles within three interacting systems - synthesis and translation, support, and implementation delivery systems - interact. PC enrollment activities during the pre-implementation phase include: individual or group interview sessions to map out current TiC processes and co-design sessions with PC teams to identify gaps/challenges. New or modified practice changes developed within co-design sessions are drawn from evidence-based practices and adapted to local contexts or built from scratch. Improvement science approaches guide current state mapping exercises whereas the Consolidated Framework for Implementation Research and Normalization Process Theory informs questions about factors within the co-design and monitoring phases that support or impede change. Results: Over 20 PC providers and their teams caring for urban, suburban, and rural patient populations are enrolled in the study. Although process mapping and co-design activities identified variability in resources to support TiC activities, improvements in education and monitoring of patients with medical complexities post-discharge is a common issue. This led to engagement with acute care partners to understand what type of education is reviewed with patients with one or more of the ADAPT focused conditions pre-discharge. We are working with PC participants and primary care network members to co-design practice changes that support continuity of education from acute care into the primary care space within urban and rural PC settings. Additionally, a change package was designed that includes a co-design and implementation guide for PC teams across the province to support TiC work. Implications: The adaptation and study of enhanced practice changes to fit to local contexts will provide PC teams within Alberta with practical steps to guide TiC work. This work also adds to the literature on evidence-based TiC processes for diverse communities and primary care practice teams.

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