A myriad of factors influencing the implementation of transitional care innovations: a scoping review
Implementation Science volume 16, Article number: 21 (2021)
Care transitions of older persons between multiple care settings are frequently hampered by various issues such as discontinuous care delivery or poor information transfer among healthcare providers. Therefore, several innovations have been developed to optimize transitional care (TC). This review aims to identify which factors influence the implementation of TC innovations.
As part of TRANS-SENIOR, an international innovative training and research network focusing on enhancing or avoiding care transitions, a scoping review was conducted. The five stages of the Arksey and O’Malley framework were followed. PubMed/MEDLINE, EMBASE, and CINAHL were searched, and eligible studies published between years 2000 and 2020 were retrieved. Data were extracted from the included studies and mapped to the domains and constructs of the Consolidated Framework for Implementation Research (CFIR) and Care Transitions Framework (CTF).
Of 1537 studies identified, 21 were included. Twenty different TC innovations were covered and aimed at improving or preventing transitions between multiple care settings, the majority focused on transitions from hospital to home. Key components of the innovations encompassed transition nurses, teach-back methods, follow-up home visits, partnerships with community services, and transfer units. Twenty-five prominent implementation factors (seven barriers, seven facilitators, and eleven factors with equivalent hindering/facilitating influence) were shown to affect the implementation of TC innovations. Low organizational readiness for implementation and the overall implementation climate were topmost hindering factors. Similarly, failing to target the right population group was commonly reported as a major barrier. Moreover, the presence of skilled users but with restricted knowledge and mixed attitudes about the innovation impeded its implementation. Among the eminent enabling factors, a high-perceived advantage of the innovation by staff, along with encouraging transition roles, and a continuous monitoring process facilitated the implementation of several innovations. Other important factors were a high degree of organizational networks, engaging activities, and culture; these factors had an almost equivalent hindering/facilitating influence.
Addressing the right target population and instituting transition roles in care settings appear to be specific factors to consider during the implementation of TC innovations. Long-term care settings should simultaneously emphasize their organizational readiness for implementation and change, in order to improve transitional care through innovations.
Innovations in transitional care (TC) are often implemented to ensure an optimal continuity of healthcare delivery for older persons who transfer between multiple care settings. Older persons aged 65 years and above are at high risk of adverse events during care transitions due to the prevalence of chronic diseases and multimorbidity [1,2,3,4,5,6,7]. Care transitions of older persons are frequently hampered by a diversity of issues, such as, but not limited to, fragmented care, medication errors, or poor communication among healthcare providers [7, 8]. Consequently, the delivery of proper TC for the older population is not always achieved.
There appears to be an urgent need to innovate in order to alleviate the augmented demand for long-term care (LTC) services and promote better and safer care transitions. Based on the World Health Organization’s concept of LTC, we adapted its definition to fit the use throughout this article as “LTC refers to the provision of continuous care activities performed by formal and/or informal/family caregivers to ensure that older persons with or at risk of a significant ongoing loss of intrinsic capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms, and human dignity; also it can be achieved through: (a) optimizing the older person’s trajectory of intrinsic capacity, (b) compensating for a loss of capacity by providing the environmental support and care necessary to maintain functional ability at a level that ensures well-being; and can be provided in settings, such as but not limited to: nursing and residential care facilities, assisted living facilities, or private/own home” . To that end, multiple evidence-based TC interventions, models, or programs also referred to as “innovations” have been developed with the goal to improve or prevent transitions between different settings . According to existing literature, we defined the following terms to be used throughout this article: “improve care transitions”—to provide and enhance the transitional care and services delivered during physical relocations of older persons from one care setting to another, with a view to creating optimal benefit as a result of the care transition; “prevent care transitions”—to provide the care and services needed in order to avert an unnecessary or avoidable physical movement of older persons between two care settings or more [2, 5, 7]. The Transitional Care Model and Coleman’s Care Transitions Intervention are examples of interventions designed to improve care transitions from hospital to home . Key components of these interventions include appointing a transition coach or nurse, encouraging patient self-management, and planning hospital discharge [10,11,12]. While other interventions  aim to prevent care transitions from nursing home to hospital through the use of specific advanced care planning tools, alternative interventions focus on providing acute care at home to prevent transitions from home to hospital . The successful implementation of these interventions has been shown to enhance the quality of care, control costs, reduce hospital readmission rates, and ultimately meet patient needs [2, 15]. However, while innovation in TC is encouraged as a solution, its implementation is often difficult and unsuccessful.
The success or failure of the implementation of any innovation within a healthcare setting is usually influenced by multiple factors recognized as either barriers or facilitators . These factors can be linked to either the innovation characteristics, individual professionals, patients and caregivers, organizational structure, or the environmental context [16, 17]. Nevertheless, other factors related to the actual process and activities undertaken to implement an innovation such as the planning, execution, and evaluation methods are as crucial . Similarly, attempts to implement innovations in TC are frequently affected by multiple factors. Among the barriers are limited organizational resources, absence of an implementation climate, complexity of the innovations, and low leadership engagement [18, 19]. Conversely, facilitators include the adaptability of innovations, a high relative advantage of the innovation as perceived by users, and the existence of robust external organizational partnerships [14, 19].
However, to the best of our knowledge, no overview exists on barriers and facilitators that influence the implementation of innovations for preventing or improving care transitions for older persons. Thus, there is a need to explore and map the available evidence on these implementation factors. The main research question of the current study is the following: What are the barriers and facilitators that influence the implementation of TC innovations for older persons in long-term care settings? A secondary question is whether the literature captured the perspectives of older persons and informal or family caregivers on the innovation’s implementation and overall experience, and if so, what was reported as feedback.
This scoping review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist  (see Additional file 1). The review was conducted according to the five stages described by the Arksey and O’Malley framework  and the enhancements proposed by Levac et al. .
Stage 1: identifying the research question
This scoping review is guided by the following question: What are the barriers and facilitators that influence the implementation of TC innovations for older persons in long-term care settings?
Stage 2: identifying relevant studies
Initially on July 25, 2019, a systematic search of three databases was conducted: PubMed/MEDLINE, EMBASE, and CINAHL; an update was run on March 10, 2020. Four main concept terms were used in the search: implementation; care transition; innovation; and older persons. To formulate the search strings, relevant keywords and synonyms were identified for each concept term in addition to the controlled vocabulary terms (such as MeSH headings in PubMed/MEDLINE). The search strategy was discussed by the authors as well as reviewed by an information specialist. Reference lists of articles that fulfilled the inclusion criteria were searched to identify additional papers. The final search strategy is available (see Additional file 2).
Stage 3: study selection
Literature published in any language between January 1, 2000, and March 10, 2020, was retrieved.
Original research studies were included. Articles were eligible for inclusion if (a) target population (participants or receiver of care) were all or if the majority were older persons aged 65 years and above (also referred to as patients, older adults, frail older adults, elderly) with long-term care needs and at risk of care transitions; (b) focused on the transfer and physical movement of older persons between two or more care settings with at least one setting providing long-term care; (c) implemented an innovation within a care setting to prevent or improve care transitions; (d) reported on the barriers and facilitators that influenced the implementation process of the innovation; (e) stated the perspectives of the older persons, family, informal caregivers, and/or healthcare providers on the innovation.
After the removal of duplicates, the first author (AF) screened the titles and abstracts for eligibility. In order to increase reliability, the second author (LG) screened a random selection of 10% of the total records for titles and abstracts . Both reviewers then compared their assessment decisions and resolved any differences through discussion and when necessary through consultation with the author (BdB). In the next phase, the two authors (AF, LG) independently screened and discussed 100% of the full texts of those articles deemed eligible [23, 24]. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flowchart  was used to report the study selection process.
Stage 4: charting the data
Development of the data charting forms
A data charting form consisting of two parts was developed. Data charting form—part 1 comprised the following: title; authors; year; country; study aim; design and methodology; population; setting; innovation description; duration and phase of implementation; presence of barriers and/or facilitators to innovation implementation; reported themes of barriers and/or facilitators to the implementation of the innovation; perspectives of older persons, family, or informal caregivers and/or providers on the innovation; and reported implications of the innovation. Data charting form—part 2 was devised to map barriers and facilitators as identified in the studies to the Consolidated Framework for Implementation Research (CFIR)  and the Care Transitions Framework (CTF) .
The CFIR is composed of five domains: (i) intervention characteristics; (ii) outer setting; (iii) inner setting; (iv) characteristics of individuals; (v) process, and 39 standardized constructs and subconstructs . This framework helps researchers identify the factors (i.e., barriers and facilitators) that influence the implementation of innovations . Moreover, specific constructs from the CTF  were selected and used in supplement to the CFIR (see Additional file 3). The CTF is an adaptation of the CFIR, whereby it incorporates all the CFIR constructs in addition to new ones, which are mostly relevant to transitional care.
Testing of data charting forms and the charting process
Both forms were tested initially on two articles, and then results were discussed critically within the research team. It was agreed to include additional elements to describe further the innovations’ features in data charting form 1. In the data charting, the implementation factors and themes were extracted from the included articles and then mapped to the CFIR’s relevant domains, constructs, and the selected CTF constructs using the CFIR codebook . Subsequently, the CFIR rating rules were used to determine each factor’s influence as negative: a barrier, or positive: a facilitator . Two authors (AF, TvA) charted data independently from five randomly selected articles. Disagreements on mapping factors to CFIR/CTF constructs were resolved between the two authors leading to a consensus. Afterwards, author AF completed the full data charting for all the included articles.
Stage 5: collating, summarizing, and reporting the results
The data charted were synthesized as follows:
Description of included studies: classification of the studies into four groups according to the care transition pathways of each TC innovation; included the author(s), year of publication, country, objective, population, design, and methods.
Description of the TC innovations: classification of the innovations into four groups according to the specific care transition pathways; included the target population, key components, and the CFIR domains influencing their implementation.
Barriers and facilitators to implementation of TC innovations: the frequency of the reported factors identified as barriers and/or facilitators to the implementation was calculated based on their presence in the number of studies.
Perspectives of older persons, family, or informal caregivers: a narrative description of the feedback on the overall experience, satisfaction with, or views on the implementation of the TC innovation.
Initially, 1537 studies were identified, and 21 were included in the final stage. The flowchart for the selection process is depicted in Fig. 1.
The 21 studies included described the implementation of 20 different TC innovations (see Table 1). Almost half of the studies (N = 11, 52%) originated from the USA, and five were from Europe. The majority of the studies were process evaluations and were performed during or post the implementation of a TC innovation to examine the influencing factors. Most studies used qualitative research methods, and 11 utilized a preselected evaluation, implementation, or quality-related framework, tool, model, or instrument to guide data collection such as interviews and/or data analysis.
Study populations across all studies were comprised of multiple healthcare professionals and providers. Only six studies included older persons or family/informal caregivers and explored their perspectives on the TC innovations [36, 37, 41, 44, 46, 47].
Key features of the TC innovations
Sixteen innovations focused on improving care transitions for older persons, while four focused on preventing transitions. TC innovations were classified into groups according to the care transition pathways (see Table 2).
Description of the four groups of TC innovations
Care transitions from hospital to home settings were the focus of ten TC innovations. Improving care transitions was the main aim of these innovations with common goals to reduce hospital readmissions, lower healthcare costs [31, 34,35,36, 39, 40], enhance older persons’ quality of life [18, 32, 33] and satisfaction [34, 39], and scale down the need for institutional care . Mostly, these innovations targeted older persons with chronic and complex conditions discharged from hospital, requiring long-term care at home, and who were at higher risk of readmission.
The common component across the innovations was the existence of a healthcare professional with a “transition role,” such as a transition nurse, health coach, care coordinator, social worker, or community nurse. The role served to ameliorate the transition journey from hospital to home by primarily providing follow-up, developing individualized care plans, and coordinating care.
Care transitions from hospital to intermediary care places to a final destination were the focus of four TC innovations. These innovations aimed to improve care transitions with common objectives, such as reducing the length of hospital stays, relieving hospital bed-blocking, and preventing inappropriate admission to residential aged care [42, 43]. All four innovations were designed for older persons who concluded an episode of acute care at hospital but were unfit to transfer to home or another final long-term care destination. The creation of “transition intermediary care places” such as transfer beds hosted within a residential care facility or community setting was the notable component across these innovations [41,42,43,44]. Hence, the four TC innovations allowed extra time to organize a more personalized arrangement for the long-term care final destination for older persons.
Care transitions from hospital or home to nursing/residential care facility were the focus of two TC innovations. The goal of these innovations was to improve care transitions with the objective to enhance information transfer between hospitals and nursing facilities and promote continuity of care. The essential aspect of both innovations was the provision of “transition advice & support” to nursing facility staff. This was enabled through the arrangement of community geriatric services and a psychiatric community nurse [45, 46].
Care transitions from nursing facility or home to hospital were the focus of four TC innovations. These innovations aimed to prevent care transitions. Hence, the main objectives were the provision of a value-based and patient-centered high-quality care , as well as the reduction and prevention of avoidable hospitalizations [47, 48], and reducing the frequency of transfers to acute hospital care . The unique component of all four innovations was “transition care management in place.”
Barriers and facilitators to the implementation of TC innovations
Factors reported in the 21 studies could be mapped to 61 CFIR&CTF constructs, out of which 19 were reported as barriers only, 8 as facilitators only, and 34 as both barriers and facilitators. Among these 34 factors, 15 were reported as having both influences concurrently in the same study. The reporting frequency, presented as number of studies, for the barriers and facilitators influencing the implementation of the transitional care innovations as mapped to the CFIR&CTF constructs is shown in Fig. 2.
The most commonly reported domains impacting implementation were process (20 studies) and inner setting (19 studies), while factors in the outer setting were least reported (12 studies). Twenty-five factors were reported by at least five studies (25%) and therefore were considered the most prominent ones. Among these factors, we distinguished seven factors as predominant barriers and seven as predominant facilitators. The remaining 11 factors showed a nearly equivalent direction of influence as impeding and facilitating (i.e., indistinguishable). Here we use “predominant” when a factor was clearly and more frequently reported as either a barrier or facilitator, judged by whether at least two thirds of the total number of studies reporting this factor reported it as a barrier or facilitator. Nevertheless, this does not directly imply that these factors are the most important, but it conveys that they are very likely to affect the implementation of TC innovations in either direction of influence. The main findings describing the most prominent factors are presented below, and Fig. 3 provides an overall summary.
A mismatch between the TC innovation components and the intended profile of the recipients, older persons, was evident to affect its implementation as indicated in nine studies [14, 18, 31, 32, 34,35,36, 43, 47]. Five studies reported that unclear eligibility criteria of the TC innovation often impeded the identification of older persons that could benefit from it [14, 18, 32, 35, 47]. Another four studies stated that TC innovations were unable to meet the specific care needs of the targeted older persons due to the high frailty and complex conditions of the recipients, confirming an incompatible fit [31, 34, 36, 43].
The intricacy of the TC innovation design and the difficulty of putting it into action were reported mutually in five studies [14, 31, 36, 38, 39]. Two studies cited that the necessity to involve multiple homecare service providers  and informal caregivers , and the absence of bundled care payment methods  led to difficulty in implementing TC innovations in home settings. Healthcare providers perceived that TC innovations with complex and extensive processes , unstandardized or detailed protocols , and hard to understand and use tools and checklists  affected the implementation negatively.
Readiness for implementation: available resources
Low staffing levels [43, 44, 46] and a lack of dedicated staff  were common impeding factors to the implementation of TC innovations. Similarly, staff turnover [38, 47, 49] plus losing key team members  and major program staff and contact persons  affected the implementation negatively. This led to increased costs and weakened relationships between organizations involved in implementing a TC innovation . Heavy workloads [38, 47, 49], time constraints [39, 46], and work schedule pressure  also hindered implementation and sometimes led to less staff engagement . Limited availability of needed resources such as equipment and care service provisions , as well as financial constraints  or a lack of funding [37, 40], were notable barriers to implementation. Moreover, three studies indicated that an inadequate training and education offered to providers and staff hindered their ability to implement new TC innovations [36, 42, 47].
A disrupted information flow, communication, or relationship between multiple healthcare providers and across organizations was described as cumbersome and impeding to the implementation of TC innovations [14, 18, 32, 34, 42, 46]. Four studies reported that an insufficient, inconsistent, or discontinuous patient information exchange between different organizations often led to delays in coordination of services and care planning, which was the essence of some TC innovations [14, 18, 34, 42]. Furthermore, the inefficient communication and difficulties in maintaining steady working relationships among the TC innovation program staff and, for example, the hospital or nursing home staff were barriers to the implementation [32, 46].
Implementation climate: relative priority
The existence of multiple quality improvement initiatives and projects within the organization often hindered the efforts to implement new TC innovations concurrently . Moreover, alternate quality improvement projects posed competition to the introduction of new TC innovations  and sometimes a mix of confusion and doubts among the staff on their need . Overall, staff described change fatigue as a main barrier to endorsing new transitional care activities, as well as leadership sometimes failing to actively endorse new transitional care programs [32, 33]. Two studies indicated that major organizational changes also created different priorities among staff and a reduced capacity and motivation to implement new TC innovations [38, 49].
Knowledge and beliefs about the intervention
The older persons’ misconceptions about the TC innovation together with a limited awareness of its specific services and goals, as well as a low perceived value, affected the enrolment process and implementation [31, 33, 36]. Moreover, some older persons expressed privacy concerns over aspects of the innovations, such as home visits by care providers, and hence viewed it as a disruption with a little value [33, 35, 36]. Similarly, mixed knowledge and beliefs surrounding the innovation , confusion on the innovation’s direction , and not knowing what is expected [44, 47] by healthcare providers were reported as hindrances to the implementation. One study cited that care home staff believed that the new intervention would make them highly liable and accountable , whereas in another study, staff saw that a mind shift is required or implementation is impeded .
Two studies indicated that following a less organized implementation plan with a low-quality and feasibility vision impeded the execution of a TC innovation [33, 39].While another four studies cited that the lack of clear initiation workflows and specific protocols [14, 47], as well as an absence of early induction and explanation of the innovation [35, 44], led to early missteps and confusion in rolling out the TC innovations [35, 47].
Four studies reported that the benefits and usefulness offered by a TC innovation facilitated its implementation [35, 38, 44, 46]. Healthcare providers stated that TC innovations with certain supportive tools, such as compiling an older person’s information during transitions between settings, helped staff work more efficiently and thereafter enhanced the implementation . In addition, an improved quality of information transfer and communication between community and nursing home settings offered by one TC innovation’s features was perceived as advantageous by staff . Moreover, the implementation of a TC innovation was facilitated when managers observed incremental benefits such as improved healthcare staff practice and skills .
Evidence strength and quality
Proven effectiveness and solid evidence on the TC innovation’s ability to ensure positive outcomes enabled its implementation [35, 39, 40]. Outcomes such as low readmission rates  and better patient satisfaction  resulting from a TC innovation led to a high buy-in from the healthcare providers  and a convinced leadership , which consequently supported the implementation.
Information technology (IT) and health information technology (HIT) resources: HIT systems
The presence of supportive electronic health information systems enhanced the implementation of TC innovations by enabling better communication, shared information documentation, and patient care management across settings [18, 36, 38, 48]. Notably, the incorporation in patients’ electronic files of either a TC innovation-specific checklist  or signaling the involvement of a TC manager in the care management  facilitated the adoption.
Defining clear roles and responsibilities for the key TC innovation implementing team members facilitated the implementation . Three studies reported that key staff played a critical role in implementation, through adhering to the application of the innovation’s specific activities [31, 32], providing regular support, and serving as a liaison and communication channel between different care settings and caregivers .
Transition roles: frontline staff
Five studies reported that the presence of frontline staff with a designated transition role facilitated the execution of a TC innovation [31, 35, 42, 44, 47]. A role directly attached to the innovation, such as transition care staff , advanced practice nurses , or a clinical nurse consultant , was vital to implement the core components of the innovation by being in direct contact with older persons and able to identify and manage their transition care needs.
Reflecting and evaluating—measurement capability and data availability
Regular communication and feedback between staff on the progress of implementing TC innovations, such as sharing successful outcome measures, fostered more leadership support for continuing the implementation [38,39,40]. Furthermore, ensuring a continuous monitoring of the innovation’s effectiveness and overall performance as well as quality and safety for patients allowed for timely adaptations in the implementation process, together with maintaining its continuity [14, 35, 38].
Eleven factors across four domains were highly reported, however with an overall nearly equivalent influence as both impeding and facilitating the implementation of a TC innovation.
Although five studies reported that pre-existing partnerships, the establishment of new external networks, or sharing of practices between various healthcare organizations enabled a faster and better implementation of TC innovations [14, 40,41,42, 46], four studies indicated poor interorganizational relationships and unwillingness to collaborate as evident barriers [33, 40, 45, 48].
External policy and incentives
The presence of external unsupportive laws and regulations, as well as the discontinuity of national funding schemes, showed a negative influence on the implementation of TC innovations in four studies [14, 35, 40, 46]. Conversely, another four studies cited that favorable extrinsic legislative changes [41, 49] or the availability of governmental sponsorship for new TC innovations were facilitators [36, 42].
Networks and communications
A challenging team formation with an absence of regular, effective, and clear communication among the members impeded the implementation, as cited in seven studies [14, 32, 34, 43, 46,47,48]. In contrast, suggested facilitators included established interdisciplinary teams , strong coordination , or cooperative working relationships across team members [35, 36, 48].
Progressive , innovative , flexible , or problem-solving [35, 49] organizational norms and values with emphasis on patient-centered care  fostered implementing new TC innovations. In contrast, a mismatch in cultures between healthcare organizations or the presence of traditional and resistant to change values was shown to hinder the implementation [35, 43, 46, 47, 49].
Readiness for implementation (leadership engagement; access to knowledge and information)
Insufficient involvement and a limited support from existing leadership along with a lack of interest in implementing a new TC innovation affected the process negatively [32, 37, 39, 43, 47]. Likewise, failing to provide the required information and initial training to staff on a new TC innovation hindered its implementation [14, 37, 44]. In contrast, a high organizational commitment and sustained leadership [35, 38, 41, 49], and ensuring the access to knowledge and mentoring on the TC innovation, facilitated the implementation [35, 38, 42].
Skills, competencies, and other personal attributes
Six studies indicated that a lack of staff expertise, knowledge capacity, and skills, along with insufficient educational levels, often delayed or ultimately hindered the implementation of TC innovations [14, 36, 38, 43, 45, 46]. Conversely, another six studies suggested that staff with a wide experience in long-term care and possessing clinical and technical skills [31, 32, 35, 44, 47, 48], as well as high critical attributes , were a great source of implementation facilitation. Similarly, low motivation levels and frustration among the staff [36, 38] or patient’s poor health literacy  and no acknowledgement of care needs  impeded implementation; yet a high motivation for change had a positive influence [31, 46, 49].
Engaging: key stakeholders, innovation participants, organizations, and external context
The challenge to involve actively and early on the key healthcare professionals, patients, family, and external providers in addition to low levels of training and induction activities impeded the implementation of various TC innovations [14, 31, 33, 39,40,41,42,43,44,45]. However, a continuous engagement of healthcare providers  and the patient [39, 44], alongside stimulating external collaborations  or ensuring family inclusion in care goals setting , fostered the implementation. Similarly, exercising team-building efforts [14, 39], gaining an early buy-in and support from key staff [32, 38, 48], and advertising the TC innovation well  were essential facilitators.
Perspectives of older persons, family, or informal caregivers on TC innovations
Six studies reported on the overall perception of the older persons and/or their caregivers regarding the transitional care innovation being implemented. Often the feedback was not specific to the implementation aspect, but rather on the innovation’s components, benefits, and satisfaction. Some components of the TC innovations, such as medication management, were perceived as a challenge for patients , whereas a transition role, such as a care coordinator , clinical nurse consultant , or community psychiatric nurse , was perceived as highly valuable and beneficial. In addition, the provision of clear information and expectations from the TC innovation was seen as highly satisfactory [44, 47]. Three studies reported that older persons and their caregivers had a mixed experience with the innovation as either satisfying or devaluing, thus sometimes feeling that the components do not fit or meet their care transition needs or wishes [36, 41, 44].
Our study identified an interplay of 25 main factors that acted as barriers and facilitators during the implementation of diverse transitional care innovations. Fourteen factors presented with a predominant direction of influence. The important barriers were linked to the organization’s implementation readiness and climate, targeted older populations, process planning, and users’ knowledge. The significant enabling factors were the innovation’s high relative advantage, transition roles of professionals, and evaluation of the implementation process. Furthermore, we could not distinguish a clear-cut direction for the influence of other key factors. By large, the current findings are in line with previous research and theories suggesting that a range of interrelated factors existing at multiple levels determine the success of the implementation of innovations [50, 51].
Our results indicate that certain factors related to the implementation process and intervention characteristics appear to be specific to transitional care innovations. While the roles of middle managers [52, 53] and champions [54, 55] were indicated as facilitators to implementing general healthcare or long-term care (LTC) innovations, transition roles of frontline staff in LTC were key in facilitating the adoption and execution of TC innovations. Moreover, awareness of existing barriers in designing and tailoring TC innovations to the target population was seen as lacking across many of the studies we reviewed. This could be explained by the specific profile and care transition needs of older persons that seem to be overlooked when developing innovations. Even though the components of some TC innovations entailed the involvement of both older persons and caregivers in the development of care plans, a mismatch of needs occurred. As presented elsewhere, it is highly important to ensure patient engagement in codesigning processes or evaluations of care improvement initiatives such as TC innovations [56, 57]. Moreover and in our attempt to answer the second research question, this review found only few studies that took the perspectives of transitional care recipients into account, while examining the implementation of TC innovations. The role of the older persons and thereby the consideration of their wishes and needs in the implementation process appear to be limited. Hence, the older persons and/or their informal or family caregivers’ reflection on the actual implementation challenges are understudied, since the providers’ perspectives are often those sought after.
Furthermore, the specific context and characteristics of LTC organizations play an integral role in implementing innovations [58,59,60,61,62]. Correspondingly, our results indicated that the LTC organizational culture, implementation climate, readiness for implementation, implementation process, the individuals’ skills and attributes, and internal communication dynamics have a major impact on the uptake of several TC innovations. This provides further evidence regarding the theory on organizational readiness for change (ORC) by Weiner , which explains that fostering the organization’s capacity, commitment, and efficacy to change are notable drivers in creating readiness and ultimately enhance implementation. Similarly, our results affirm the work of Attieh et al. , in which five core theoretical components of ORC were identified including the organizational dynamics, change process, innovation readiness, institutional readiness, and personal readiness. Our results indicate that lacking resources often hindered the implementation of various TC innovations, and that the organizational culture had a prominent yet mixed influence on bringing about a change. According to Weiner , organizational resources and culture are among the contextual factors that can affect the organizational capacity and readiness for change. This review also identified that the individuals’ skills, knowledge, perceived attitudes, and designated roles were prominent factors in implementing an innovation. This is evident as per Holt’s et al.  and Weiner’s  concepts of change efficacy, which explain that individuals in an organization with a high shared collective capability and confidence to implement new tasks successfully can enhance the organizational readiness for change. In addition, our findings on the importance of implementation climate explained by the individuals’ relative priority to implement a TC innovation within an organization as well as their motivation levels relate to the organizational change commitment [63, 65, 66]. Lastly, the literature indicated that organizational leadership and internal communication dynamics are instrumental in generating readiness for change, as was mirrored in our results [63, 66].
Prospective studies on the degree of influence of each identified barrier and facilitator on the implementation of a TC innovation are needed. This will enable the development of tailored implementation strategies by addressing the prioritized factors. Furthermore, focusing on the older person’s perspective when studying the implementation process of TC innovations is required. This will alleviate the discontinuous and problematic care transitions for the older population.
Policy and practice in transitional care
Future implementation of TC innovations can benefit from a preassessment of the key components that underpin an LTC organization’s readiness for change by using established ORC measurement instruments . Overall, these measures can offer an initial support for LTC organizations to better prepare for implementing innovations by reducing blinded change efforts. Simultaneously, LTC organizations can leverage their readiness for implementing change by, for example, adopting the concept of innovation management as reflected in A.T. Kearney’s House of Innovation . This framework invites organizations to start with an innovation strategy and build an innovative and open culture. In addition, organizations must manage the innovation’s process in an integrated and continuous manner from idea conception to implementation, as a way to avoid inefficiencies and ensure timely positive outcomes. Bates et al.  emphasized the power to create successful innovative healthcare environments by making innovation a strategic priority. Henceforth, we recommend LTC organizations bolster their innovation readiness and management, whereby they encourage among professionals an incessant mindset of “change is the norm.” Nevertheless, this readiness should be fostered across the continuum of care spanning multiple LTC settings, given the nature of TC. In addition, transition roles or implementation support practitioners  should be instituted to better operationalize innovations in TC.
Strengths and limitations
We consider the combined use of CFIR and CTF a methodological asset for conducting this review, especially in the process of data extraction and mapping of factors. The CFIR provided an intricate yet systematic way to understand the interconnectedness of the numerous factors. The inclusion of constructs from the CTF was found vital in detecting factors specific to care transitions. On the other hand, we acknowledge that different or additional factors could have been found had we chosen to use another framework.
This review has some limitations. First, it is subject to publication bias, since we only included articles published in peer-reviewed journals and excluded gray literature, preregistries, and policy documents. Second, even though we used an extensive search strategy to identify relevant studies on implementing TC innovations, we might have missed some potentially relevant papers, as the aim of innovations in LTC is not always clearly described. Third, not all records were screened by two persons; only a random selection of 10% of the initial total records was screened by a second reviewer for titles and abstracts. Though agreement seemed satisfactory, we cannot fully rule out that some relevant sources could have been missed. Fourth, we did not perform critical appraisal for the included studies, even though it is not mandatory in scoping reviews’ methodology, it could have added to the interpretability of the findings.
A diversity of factors impact the implementation of TC innovations; these include the innovation’s complexity, relative advantage and evidence strength, organizational readiness for implementation, individuals’ knowledge and beliefs, and the implementation process planning and evaluation. To ensure implementation potential, TC innovations need to address the right older target population, and transition roles for staff should be developed as key steps. LTC organizations can benefit from collaborating and leveraging concurrently their readiness for change along with adopting innovation management in order to succeed in implementing TC innovations. Furthermore, minimizing the confusion around how implementing innovation works holds the potential to improve care transitions for older persons.
Availability of data and materials
Data generated and analyzed during this study are avaliable from the corresponding author on reasonable request.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews
Preferred Reporting Items for Systematic Reviews and Meta-analyses
Consolidated Framework for Implementation Research
Care Transitions Framework
Health information technology
Organizational readiness for change
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The authors thank Dr. Ramon Daniels for providing feedback on the discussion section of the manuscript.
The current project is part of the research program TRANS-SENIOR Innovative Training Network funded by the European Union (more information is available on https://www.trans-senior.eu/). This project has received funding from the European Union’s Horizon 2020 research and innovation program under the Marie Skłodowska-Curie grant agreement No. 812656.
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PRISMA-ScR checklist. This file describes a checklist of items that are covered and reported in this scoping review as per the PRISMA-ScR.
Search strategy for electronic databases. Microsoft Word Document (.docx). This file includes the search strategy for the databases PubMed/MEDLINE, EMBASE, & CINAHL.
Consolidated Framework for Implementation Research & Care Transitions Framework constructs description. This file provides the description and definitions of the CFIR constructs and the constructs selected and used from the CTF.
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Fakha, A., Groenvynck, L., de Boer, B. et al. A myriad of factors influencing the implementation of transitional care innovations: a scoping review. Implementation Sci 16, 21 (2021). https://doi.org/10.1186/s13012-021-01087-2