Table 1 Characteristics of the 21 included studies

 Bradway et al. 2012, USA [31]

To describe the barriers and facilitators to implementing a transitional care intervention for cognitively impaired older adults and their caregivers led by advanced practice nurses

➢ Post-implementation

APN-directed TCM: Advanced Practice Nurse-Directed Transitional Care Model

Healthcare professionals (n = 3):

▪ Advanced practice nurses

Exploratory qualitative:

▪ Case summaries for patient-caregiver dyads completed by APNs at end of intervention—15 randomly selected

▪ Field notes taken by study investigators during biweekly APNs’ case conferences

 Couture et al. 2016, Canada [18]

To evaluate and explain the barriers and facilitators to the implementation of a pilot intervention—introducing the role of transitional care managers within a public healthcare system

➢ During implementation

TCM Role: Transitional Care Manager Role

Healthcare professionals (n = 29):

▪ Transitional care managers

▪ Hospital workers

▪ Social workers

▪ Staff of health and social service centers

Process evaluation:

▪ Assessed the fidelity, acceptability, and appropriateness (contextual factors)

▪ Focus groups

▪ Direct observations

▪ TCMs’ activity grids and logbooks

▪ Meeting minutes and documents of coordinating and implementation committee

 Hung et al. 2015, USA [32]

To examine and describe the successes and challenges of the implementation of a pilot community-based transitional care program

➢ Post-implementation

Community-based TCP: Community-based Transitional Care Program

Healthcare professionals and program’s management team (n = 7):

▪ Interprofessional team of program staff (nurses, social workers)

▪ Members of program’s steering committee

Qualitative:

▪ Semi-structured interviews guided by the Organizational Readiness to Change Assessment instrument

▪ Analysis using PARIHS framework (contextual factors, evidence, facilitation techniques)

 Hung et al. 2018, USA [33]

To examine the key contextual features enabling the implementation and hospital-wide scaling of a community-based transitional care program

➢ Post-implementation

Community-based TCP: Community-based Transitional Care Program

Healthcare professionals and program’s management team (n = 17):

▪ Program director and manager

▪ Program staff (nurses, social workers, wellness coaches)

▪ Members of program’s steering committee

Qualitative:

▪ Semi-structured interviews guided by the Organizational Readiness to Change Assessment instrument

▪ Analysis using Care Transitions Framework (domains—intervention, organizational, and patient characteristics, implementation process, measures, and outcomes)

 McNeil et al. 2016, Canada [34]

To evaluate the effectiveness and identify barriers to and facilitators of the implementation of an intervention involving patient handoff between a hospital-based care transitions nurse and a community-based response nurse

➢ Post-implementation

CTI-Handoff: Care Transition Intervention Handoff

▪ Care transitions and rapid response nurses (n = not specified)

▪ Managers and executives (n = 4)

Qualitative:

▪ Focus group discussions

▪ Individual interviews

 Naylor et al. 2009, USA [35]

To identify the major facilitators and barriers to implementing the Transitional Care Model in an insurance organization over the phases of start-up and roll-out

➢ Pre- and during implementation

TCM: Transitional Care Model

Healthcare professionals and project team (n = 19):

▪ Implementation staff

▪ Case managers

▪ Transitional care nurses

▪ Senior leaders and managers

Qualitative:

▪ Semi-structured interviews guided by Everett Roger’s framework for diffusion of innovations (focus on: staff involvement, culture, communication channels, model integration within organization, ease/difficulty of start-up phase)

 Nurjono et al. 2019, Singapore [36]

To evaluate the implementation fidelity of a transitional care program

➢ Post-implementation

NUHS-RHS TCP: National University Health System-Regional Health Systems Transitional Care Program

Healthcare professionals (n = 25):

▪ Care coordinators, program managers, physicians

○ Family caregivers (n = 45)

Realist evaluation:

▪ Using the Conceptual Framework of Implementation Fidelity (moderating factors: context, participant responsiveness, program complexity, facilitating strategies, recruitment)

▪ Interviews

▪ Observations

▪ Reviews of medical records and program databases

 Parrish et al. 2009, USA [37]

To identify factors that promote the sustainability of the implementation of a care transition intervention pilot

➢ Post-implementation

CTI: Care Transitions Intervention

▪ Pilot project team members for 10 sites (n = 30–40)^a, including transition coaches (n = at least 10)^a

○ Patients (n = 791, out of which 69.4% are aged 66+)

Mixed methods:

▪ Surveys

▪ Interviews

▪ Final project narrative reports, data reports

▪ Comparison of pre- and post-project sustainability plans

▪ 5 variables used to assess sustainability factors (leadership, transition coaches staff, project management, team commitment, sustainability plan)

▪ Care Transition Measure (CTM) to assess quality of care transition

▪ Patient Activation Assessment (PAA) to assess level of patient activation in the 4 pillars of the CTI

 Rosstad et al. 2015, Norway [38]

To investigate the implementation process of a care pathway for elderly patients into the daily practice of healthcare professionals

➢ During and post-implementation

PaTH: Patient Trajectory for Home-dwelling elders

Healthcare professionals (n = 60):

▪ Home care managers

▪ Home care head nurses

▪ Nurses

▪ Nursing assistants

Comparative qualitative process evaluation:

▪ Semi-structured interviews guided by questions focused on staff involvement and expectations, care pathway introduction and efforts to use it, challenges, promoting factors, benefits, sustainability

▪ Focus group discussions

▪ Field notes (by study investigator on overall implementation process)

▪ Meeting minutes (conference calls with head nurses and home care managers performed by study investigator)

▪ Analysis guided by the Normalization Process Theory core constructs (coherence, cognitive participation, collective action, reflexive monitoring)

 Williams et al. 2014, USA [39]

To examine the successes and failures experienced by implementing Project BOOST aiming to enhance transition from hospital to home

➢ During implementation in cohorts and post-implementation in pilot sites

BOOST: Better Outcomes by Optimizing Safe Transitions

▪ Local team leaders of (n = 6 pilot hospital sites)

▪ Hospital team leaders of (n = 27 cohort sites)

Evaluation:

▪ Telephone interviews guided by basic implementation questions and opinions on intervention elements in pilot sites

▪ Survey with hospital cohorts on implementation occurrence, when, and how

 Xiang et al. 2018, USA [40]

To examine the experiences of community-based organizations implementing the Bridge Model of Transitional Care, and identify facilitators and barriers associated with the implementation and sustainability of the model

➢ During and post-implementation

The Bridge Model

Healthcare professionals (n = 13):

▪ Clinical supervisors

▪ Program coordinators

Qualitative case study:

▪ Semi-structured interviews by telephone, guided by 3 domains of successful implementation of the PARIHS framework (evidence, context, leadership, evaluation, facilitation)

 Everink et al. 2017, the Netherlands [41]

To evaluate the feasibility of implementing an Integrated Care Pathway in Geriatric Rehabilitation

➢ Post-implementation

ICP Geri-Rehab: Integrated Care Pathway in Geriatric Rehabilitation for People with Complex Health Problems

Healthcare professionals (n = 19):

▪ Elderly care physicians

▪ Nurses (specialized, discharge)

▪ Physiotherapists

▪ Professionals from home care organizations

○ Informal caregivers (n = 37)

○ Patients (n = 113)

Process evaluation:

▪ Using Saunders and colleagues framework (fidelity, dose delivered, satisfaction, contextual and external factors)

▪ Semi-structured group interviews

▪ Face-to-face interviews

▪ Self-administered questionnaires

▪ Patient files

▪ Meeting minutes

 Masters et al. 2008, Australia [42]

To examine reports from providers to reveal enablers and barriers to compliance with the key requirements of a transition care program

➢ Post-implementation

TC Places: Transition Care Places

▪ Organizations providing transition care services (n = 23 organizations)

Qualitative:

▪ Content analysis of quality self-reports

 Plochg et al. 2005, the Netherlands [43]

To assess the functioning and implementation of an intermediate care model between a hospital and a residential home

➢ Post-implementation

ICM: Intermediate Care Model

Healthcare professionals and management staff from the residential home and medical center (n = 21):

▪ Leadership (general manager, director, head of care department, chair board of directors, chair of medical specialists)

▪ Physicians

▪ Nurses (liaison, geriatric nurse specialist, liaison nurse-head of discharge unit, registered nurse-head of transfer unit, nursing assistant of transfer unit)

▪ Occupational/physical therapists

Process evaluation:

▪ Semi-structured interviews

▪ Analysis using a typology of quality systems based on 5 elements (structural assets, allocation of responsibilities, protocols, information transfer, and monitoring/feedback cycles), and Grol’s model on effective implementation

 Renehan et al. 2013, Australia [44]

To evaluate the implementation and effectiveness of a Transition Care Cognitive Assessment and Management Pilot

➢ Post-implementation

TC CAMP: Transition Care Cognitive Assessment and Management Pilot

Healthcare professionals (n = 17):

▪ TC CAMP facility and health services staff (nursing, management, allied health, team leaders, therapists, clinical nurse consultant)

▪ Unit managers of final destination facility

○ Family caregivers (n = 7)

Process and outcome evaluation:

▪ Structured interviews

▪ Focus group discussions

▪ Medical records file audits

 Sutton et al. 2016, UK [45]

To characterize the challenges experienced in a quality improvement project aiming to improve transitions for older people

➢Post-implementation

QIP-TC: Quality Improvement Project to Improve Transitions of Care for Older People

Healthcare professionals and project team (n = 12):

▪ Care home staff (managers, owners, assistants, frontline)

▪ Hospital-based staff

▪ Project staff

Ethnographic process evaluation:

▪ Observations

▪ Semi-structured interviews

▪ Project documents (progress reports, meeting minutes)

 Van Mierlo et al. 2015, the Netherlands [46]

To evaluate a mental healthcare transfer intervention after the movement of a person with dementia into a nursing home, and to investigate factors that influence its successful implementation

➢ Post-implementation

CPN: Follow-up visit by Community Psychiatric Nurse

Healthcare professionals (n = 28):

▪ Professional nursing home carers

▪ Community psychiatric nurses

▪ Nursing home managers

▪ Outpatient clinic managers

▪ General practitioners

▪ Team manager—center for people with dementia

▪ Healthcare insurer

○ Family caregivers (n = 5)

Evaluation:

▪ Semi-structured interviews based on the Theoretical Model of Adaptive Implementation (external factors, different phases and levels of implementation process)

 Brody et al. 2019, USA [14]

To examine the barriers to and facilitators of the implementation of Hospital at Home Plus 30 days of transitional care program during its first year of operation

➢ During implementation

HaH Plus program: Hospital at Home Plus Program

Healthcare professionals (n = 27):

▪ Team physicians

▪ Nurse practitioners/leaders

▪ Social workers

▪ Leadership staff

▪ Executives

▪ Home health agency staff

Qualitative:

▪ Primers to help recall of key events/factors and develop interview guide

▪ Semi-structured interviews

▪ Focus group discussions

 Ersek et al. 2018, USA [47]

To explore the stakeholders’ perspectives on the implementation of OPTIMISTIC program, which aims to reduce hospitalizations from nursing facility; specifically the program’s effective components, facilitating adoption features, and barriers to implementation

➢ During implementation

OPTIMISTIC: Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care project

Healthcare professionals (n = 53):

▪ Primary care providers

▪ Nursing home staff and leadership

▪ OPTIMISTIC clinical staff

○ Family members of nursing home residents (n = 10)

Evaluation:

▪ Using Stetler framework of formative evaluation

▪ Semi-structured group and individual interviews

 Hirschman et al. 2017, USA [48]

To describe the experiences of healthcare providers involved in adapting and testing the feasibility of implementing a care innovation by combining two models: the patient-centered medical home and the transitional care model

➢ Post-implementation

PCMH + TCM: Patient-Centered Medical Home + Transitional Care Model

▪ Transitional care nurses (n = 2)

▪ Clinicians (n = 2–4/site^a, 5 sites)

Qualitative:

▪ Surveys (open-ended questions)

 Rask et al. 2017, USA [49]

To identify contextual and implementation factors impacting the effectiveness of an organizational-level intervention to reduce preventable hospital readmissions from affiliated skilled nursing facilities (SNFs)

➢ Post-implementation

INTERACT II: Interventions to Reduce Acute Care Transfers

▪ Quality improvement organization staff (n = 4)^a

▪ Leaders and nurses of SNF corporations (n = 6)^a

▪ SNF staff (n = 2–3/facility)^a

Evaluation:

▪ Interviews with open-ended questions based on contextual factors’ domains of the Model for Understanding Success in Quality tool (external environment, organization, QI support and capacity, microsystem, miscellaneous)