Transitional care: the evolution of an ever-green service to make integrated care happen

Abstract

The coordination of care across the health care continuum represents the most critical organisational knot to meet the actual implementation, management, and outcome evaluation of a patient’s care plan. In fact, poor coordination of services, fragmentation of treatments, lack of discharge planning and ineffective handoff of information between care providers can lead to poor transitions and, in turn, can cause overlaps with treatment plans, duplicative testing, discrepancies in medications, missed physician follow-up, patient dissatisfaction and, consequently, burgeoning of health care costs. Transitional Care TC models are gaining increasing value and a wide spread out, at the international level, to improve the quality and efficiency of health services’ delivery and have been piloted and tested in different Countries as well as within different healthcare service delivery models and organisations. TC models have a long-lasting presence in the literature if we consider discharge management and planning services, however, analysis of the emergence of new TC models, especially exploiting the health service management perspective and the interest to generalise models of care to support health managers and policy makers are very limited. In this line, there is a widespread recognition across experts that more research is needed on services organisations. In this broad scenario, we aim to provide a comparative analysis of TC patterns across Europe by cross-tabulating independent and dependent variables featuring the institutional and organisational context of development. We therefore aim to explore what are the main characteristics of the health service delivery model; what are the opportunities, threats and levers of improvement across different organisational configurations; and to what extent organizational arrangements of TC models may impact their capacity to influence the health service delivery model, the strategic planning and indeed the capacity to meet patients’ needs. We employed mixed methods in order to exploit a multiple case-study analysis. These included a literature review of theoretical frameworks and TC experiences developed at an international level and an in-depth analysis of several TC experiences analysing local documents and interviewing key managers of the services. Whereas the new models of TC retain the original objectives of discharge management and planning services, their role and organisation is changing dramatically within the renewed model of delivery designed by managed care models and the search for integration across the overall care system from community to acute to end of life care. Of interest, in most cases, either due to the complexity of the new TC models, which require not only discharge management but the overall management of patient and of transitions across care settings, or due to the fragmentation of services, TC services have been externalised to new agencies or services outside the delivery system i.e. the service centre. The latter organisational choice allows TC models to serve the organisations as well as the patients and families. On the contrary, where TC models have been established within healthcare organisation, they are located as a strategy service unit belonging to the strategic board of managers, but these patterns serve only the organisation and not the patients.