Understanding Care Transitions Before, During and Post COVID-19: Patient/Family, Care Provider and System Experiences

• Published in: International journal of integrated care 2022-05, Vol.22 (S2), p.177
• Main Authors: Kovacs Burns, Katharina, George, Marian
• Format: Article
• Language: English
• Subjects: Capitation; COVID-19; Patients
• ISSN: 1568-4156; 1568-4156
• DOI: 10.5334/ijic.ICIC21262

IntroductionOne 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 Theory or MethodsExploring 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 within Alberta Health Services (AHS), Canada. We co-designed relevant experience, process and outcome/impact experience indicators/measures with patients/clients, families and care providers regarding care transitions across acute and community settings; 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.Highlights or Results or Key FindingsThe study involved the Provincial Seniors and Continuing Care Advisory Council, Continuing Care Quality Committee and eight pilot settings involving community and Transitions in Care programs across the five zones of AHS. Each care setting involved care providers and patient/family advisors in co-designing and implementing the initiative, including survey development, and gathering, analyzing and interpreting client/patient experiences. Findings in each of the eight pilots included more detailed patient/family and care providers experience indicators/measures for transitions in care across settings. Clear themes for what makes transitions in care successful are also identified – e.g. clear communication, navigation and information direction for all stakeholders. The aggregated findings have guided the development of a set of core transition in care measures from across acute points of care including Emergency and care units, to vario