Understanding Facilitators and Barriers to Care Transitions: Insights from Project ACHIEVE Site Visits.

BACKGROUND: Care transitions between clinicians or settings are often fragmented and marked by adverse events. To increase patient safety and deliver more efficient and effective health care, new ways to optimize these transitions need to be identified. A study was conducted to delineate facilitators and barriers to implementation of transitional care services at health systems that may have been adopted or adapted from published evidence-based models. METHODS: From March 2015 through December 2015, site visits were conducted across the United States at 22 health care organizations-community hospitals, academic medical centers, integrated health systems, and broader community partnerships. At each site, direct observation and document review were conducted, as were semistructured interviews with a total of 810 participants (5 to 57 participants per site) representing various stakeholder groups, including management and leadership, transitional care team members, internal stakeholders, community partners, patients, and family caregivers. RESULTS: Facilitators of effective care transitions included collaborating within and beyond the organization, tailoring care to patients and caregivers, and generating buy-in among staff. Commonly reported barriers included poor integration of transitional care services, unmet patient or caregiver needs, underutilized services, and lack of physician buy-in. CONCLUSION: True community partnership, high-quality communication, patient and family engagement, and ongoing evaluation and adaptation of transitional care strategies are ultimately needed to facilitate effective care transitions. Health care organizations can strategically prioritize transitional care service delivery through staffing decisions, by making transitional care part of the organization's formal board agenda, and by incentivizing excellence in providing transitional care services.

Human papillomavirus vaccine series completion: Qualitative information from providers within an integrated healthcare organization.

OBJECTIVE: This qualitative study aimed to identify doctors' and nurses' perceptions of patient-, provider-, and system-level factors associated with human papillomavirus (HPV) vaccine completion that may be targets for intervention. METHODS: We analyzed data from 61 qualitative interviews with pediatricians, family medicine physicians, and immunization nurses at medical centers that had the highest and lowest HPV vaccine completion rates within the same health care system. RESULTS: In both groups, almost all providers reported strong support for the HPV vaccine. In detailing how they talk to parents and patients about the vaccine, more of the providers working at higher completion centers described using effective communication techniques, including engaging parents and patients in two-way conversation and demonstrating awareness of cultural and practical barriers to completion that families may face. Providers at higher completion centers were also more likely to depict a local medical culture supportive of and committed to HPV vaccine completion, with greater levels of proactivity and teamwork. In contrast, providers working at lower completion medical centers described a lack of proactivity, and the strategies they suggested to improve HPV vaccine completion tended to be approaches that someone other than medical providers would implement. The comments made by these providers sometimes reflected a level of negativity and judgment absent from the comments of providers at higher completion centers. CONCLUSION: Interventions to improve HPV vaccination completion rates should address both individual- and system-level factors. Improving communication skills, encouraging a supportive medical culture, and addressing resource issues is likely to improve vaccine adherence.