From Hospital to Home: Providers’ Experiences of Collaboration when Facilitating Care Transitions across Palliative Care Settings
Bibliographic record
Abstract
Research shows that many patients with advanced illness prefer to receive care and die in their homes; therefore, transitions from acute care to community settings are common. However, while many studies have examined the patient and caregiver experience of this transition process, few studies have focused on the provider’s perspective. This qualitative study explored interprofessional and interorganizational collaboration among providers when transitioning patients from hospital to home in the context of palliative care. Four themes were elucidated that reflect providers’ experiences of collaboration within and across palliative care settings. Key barriers include a perceived lack of formalized leadership roles and having continuously changing inpatient providers involved during discharge planning, inconsistent communication during patient handovers, and insufficient system-level infrastructure to support information sharing across settings. The findings of this study reveal several opportunities at the organizational and broader health system levels to better assist providers in supporting these types of transitions.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.014 | 0.028 |
| Meta-epidemiology (narrow) | 0.000 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.011 | 0.007 |
| Scholarly communication | 0.007 | 0.005 |
| Open science | 0.002 | 0.009 |
| Research integrity | 0.002 | 0.004 |
| Insufficient payload (model declined to judge) | 0.003 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".