Heterogeneity and misaligned incentives in discharge transition programs: Insights from a multisite rapid qualitative study.

Abstract

Transitions of care (ToC) programs are important for patient safety, but their implementation and success remain highly variable across US hospitals, particularly for patients with multimorbidity and health-related social needs (HRSNs). Hospitalists, as key decision-makers at discharge, encounter firsthand the factors that hinder the success of ToC programs. To explore hospitalists' perspectives on successes, shortcomings, and implementation barriers in ToC programs, particularly during transitions from hospital to community settings. Rapid qualitative study featuring virtual focus groups with participants from the Hospital Medicine Reengineering Network (HOMERuN). Data were analyzed using a mixed inductive-deductive framework to identify key themes. Twenty-two individuals from 19 different organizations participated in focus groups. None of the organizations offered comprehensive ToC programs to all patients. Four major themes emerged: (1) Diagnosis-specific ToC programs are effective but contribute to care fragmentation, particularly for patients with multimorbidity; (2) postdischarge follow-up is hindered by limited appointment availability, insurance barriers, and geographic challenges; (3) ToC programs often fail to address patient preferences, HRSNs, and health literacy, and lack adequate resources and leadership support; (4) successful programs require institutional commitment, dedicated funding, interprofessional collaboration, and community engagement. Participants emphasized the need to prioritize patient-centered care over financial return on investment. Current ToC programs are fragmented, undermining safe and equitable transitions. Addressing HRSNs, fostering leadership support, and prioritizing patient-centered care over short-term financial metrics are essential for improving ToC outcomes.