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Conference Abstracts

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

Authors:

Katharina Kovacs Burns ,

Alberta Health Services and University of Alberta, CA
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Marian George

CA
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Abstract

Introduction

One 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 Methods

Exploring 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 Findings

The 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 various community-based care settings including Home Care, Long-term or other program and care services/settings – e.g. CHOICE programs.

Conclusions

Understanding the experiences of patients/clients, families and care providers regarding care transitions between acute and community-based settings are essential to understanding what works well and where there are ‘holes’ in the system leading to failed or unsatisfactory transitions across different care settings. Such findings guide quality and safety improvement.

Implications for applicability/transferability sustainability and limitations

These core measures are being tested for transferability across all care transition settings. As well, practice, policy and service changes involving care transitions resulting from the impact of COVID-19 are noted for how care settings involving specific transition programs will adapt to “new norms”. Further measurement continues.

How to Cite: Kovacs Burns K, George M. Understanding Care Transitions Before, During and Post COVID-19: Patient/Family, Care Provider and System Experiences. International Journal of Integrated Care. 2022;22(S2):177. DOI: http://doi.org/10.5334/ijic.ICIC21262
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Published on 16 May 2022.

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