Patient safety and quality are compromised during transitions of care across settings. Interventions targeted at improving transitions have been developed and implemented widely. However these interventions have failed to consistently demonstrate measurable improvements. The literature suggests that context plays a role in mitigating the effectiveness of the interventions, however there are few studies that examine this in depth and disagreement around the best methods to do so.
The promise – and disappointment – of care transition interventions has been seen in Ontario with the limited success of the interventions implemented. This thesis explores interaction of context and the intervention through three Ontario case studies.
This thesis was informed by realist evaluation, which is concerned with understanding what contextual attributes inhibit or foster the success of interventions across settings. Case studies were developed using data gathered from 40 semi-structured key informant interviews, as well as observation and document review.
Realist evaluation informed the research approach, and a framework was developed to guide data interpretation and analysis. The framework addresses a gap in the literature around which attributes of context are most important. The framework divides context into external factors (policy), organizational structural characteristics, teamwork and culture, and management tools. Analysis within, and across cases was conducted to discern similarities around the interaction of context and care transition interventions. Key findings are: Pilot project funding was a lever for introducing the interventions. However, pilot interventions did not address policy barriers, and developed parallel processes for transitions, with sustainability implications.
Physician leadership was important, and facilitated by remuneration incentives. A significant physician role, however, crowded out other professionals traditionally involved in transitions of care.
Interventions were facilitated by prior interorganizational relationships, either formal or informal. Boundary spanners, or previous collaborations facilitated relationships in an environment where policy barriers (e.g. privacy) inhibited collaboration around transitions.
Interventions are change processes that require change management efforts and support for staff buy-in.
The results of this study contribute to a better understanding of how context can facilitate or obstruct change processes, and desired outcomes associated with care transition interventions.