A myriad of factors influencing the implementation of transitional care innovations: a scoping review

Background 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. Methods 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). Results 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. Conclusions 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. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-021-01087-2.


CTF Location of intervention activity
Components of the intervention conducted outside the hospital/clinic/office setting using external service providers and organizations.

CTF Workflows
Tasks and workflows, including interdependencies between them that are the focus of the intervention or will be affected by it.

CTF Task/Process standardization
Degree to which the intervention seeks to standardize tasks and processes that require iterative consultation.

CTF History
Experiences with similar interventions within the organizations or within the target groups.

II. Domain: OUTER SETTING A Patient Needs & Resources
The extent to which patient needs, as well as barriers and facilitators to meet those needs, are accurately known and prioritized by the organization.

B Cosmopolitanism
The degree to which an organization is networked with other external organizations.

C Peer Pressure
Mimetic or competitive pressure to implement an intervention; typically because most or other key peer or competing organizations have already implemented or are in a bid for a competitive edge. D External Policy & Incentives A broad construct that includes external strategies to spread interventions, including policy and regulations (governmental or other central entity), external mandates, recommendations and guidelines, pay-for-performance, collaboratives, and public or benchmark reporting.

CTF Technological Environment
The technological trends and movements and the availability of technological innovations that may affect the intervention and its context.

CTF Population Needs and Resources
Prevalence of conditions and disease in the population served and the characteristics of the community that are determinants of health status.

CTF Community Resources
Availability and access of service providers, aging resources, and multiple levels of community services and supports not directly involved in the intervention.

III. Domain: INNER SETTING A Structural Characteristics
The social architecture, age, maturity, and size of an organization.

B Networks & Communications
The nature and quality of webs of social networks and the nature and quality of formal and informal communications within an organization.

C Culture
Norms, values, and basic assumptions of a given organization.

D Implementation Climate:
The absorptive capacity for change, shared receptivity of involved individuals to an intervention, and the extent to which use of that intervention will be rewarded, supported, and expected within their organization.

D.1 Tension for Change
The degree to which stakeholders perceive the current situation as intolerable or needing change.

D.2 Compatibility
The degree of tangible fit between meaning and values attached to the intervention by involved individuals, how those align with individuals' own norms, values, and perceived risks and needs, and how the intervention fits with existing workflows and systems.

D.3 Relative Priority
Individuals' shared perception of the importance of the implementation within the organization.

D.4 Organizational Incentives & Rewards
Extrinsic incentives such as goal-sharing awards, performance reviews, promotions, and raises in salary, and less tangible incentives such as increased stature or respect.

D.5 Goals and Feedback
The degree to which goals are clearly communicated, acted upon, and fed back to staff, and alignment of that feedback with goals.

D.6 Learning Climate
A climate in which: a) leaders express their own fallibility and need for team members' assistance and input; b) team members feel that they are essential, valued, and knowledgeable partners in the change process; c) individuals feel psychologically safe to try new methods; and d) there is sufficient time and space for reflective thinking and evaluation.

CTF Mandate
Whether compliance with the intervention is expected within the organization.

CTF Accountability
Whether entities are subject to tangible consequences for noncompliance. E Readiness for Implementation: Tangible and immediate indicators of organizational commitment to its decision to implement an intervention.

E.1 Leadership Engagement
Commitment, involvement, and accountability of leaders and managers with the implementation.

E.2 Available Resources
The level of resources dedicated for implementation and ongoing operations, including money, training, education, physical space, and time.

E.3 Access to Knowledge & Information
Ease of access to digestible information and knowledge about the intervention and how to incorporate it into work tasks.

CTF Staff Commitment
The degree of clinician, transitional, and community care staff, patient, and caregiver involvement in transition planning CTF IT and HIT Resources: Technological infrastructure in place to support electronic information management, including IT that crosses organizations.

CTF HIT Systems
Electronic information management infrastructure and technologies available to clinicians to manage patient care, data, and communications.

CTF IT Systems
Technological systems and capabilities to support care transitions.

CTF HIT/IT Accessibility
Includes features of the physical, technical, and social environment in the organization that determine the use, accessibility, and acceptability of technology in patient care.

CTF Other Resources
Resources for implementation and ongoing operations to support change and innovation, including grant or other funding specific to care transitions. CTF Patient Self-management Infrastructure Training, counseling, and education available to patients prior to the intervention within the hospital and ambulatory setting.

CTF Continuity
Information continuity (exchange of information) and relationship continuity, both with providers and patients/caregivers and across organizations.

CTF Patient/caregivercenteredness
Extent to which the organization(s) knows and prioritizes patient and caregiver goals, needs, and preferences, and has the resources and services to meet them

IV. Domain: CHARACTERISTICS OF INDIVIDUALS A Knowledge & Beliefs about the Intervention
Individuals' attitudes toward and value placed on the intervention as well as familiarity with facts, truths, and principles related to the intervention. B Self-efficacy Individual belief in their own capabilities to execute courses of action to achieve implementation goals.

C Individual Stage of Change
Characterization of the phase an individual is in, as he or she progresses toward skilled, enthusiastic, and sustained use of the intervention.

D Individual Identification with Organization
A broad construct related to how individuals perceive the organization, and their relationship and degree of commitment with that organization.

E Other Personal Attributes
A broad construct to include other personal traits such as tolerance of ambiguity, intellectual ability, motivation, values, competence, capacity, and learning style.

CTF Collective Efficacy
Conviction of individuals and teams involved that the intervention can be carried out in cooperation with each other.

CTF Skills and Competencies
Degree of relevant subject matter expertise, skills, and competencies within the implementing team, unit, and organization.

CTF Role
Individual's role and responsibility for the intervention. The degree of multiple or shared roles.

CTF Authority
Individual provider's perceived and actual degree of authority to make decisions and act autonomously.

CTF Socioeconomic Demographics
Characteristics related to the individual's socioeconomic status.

CTF Patient Needs and Resources
Patient priorities for health and health care priorities and the social and economic capital to address those priorities.

CTF Caregiver Needs and Resources
Caregiver priorities for health and health care, and the social and economic capital to address those priorities.

V. Domain: PROCESS A Planning:
The degree to which a scheme or method of behavior and tasks for implementing an intervention are developed in advance, and the quality of those schemes or methods.

CTF Assessing
Formal assessment of care transitions issues; the needs of the users; barriers to change; the timing of these activities relative to implementation.

CTF Contingency Planning
Plans for adaptation in response to various scenarios and outcomes.

CTF Acquiring and Allocating Resources
Resources dedicated to implementing the intervention; the adequacy of those allocations.

CTF Process Ownership
The diversity of transition roles involved in processes of implementation; authority and accountability for these activities.

CTF Transition Roles:
Roles of individuals involved in the decision to adopt, execute, and facilitate the intervention.

CTF Organizational Leaders
Managers and others with the authority to dedicate resources and make decisions to adopt, maintain, or abandon the implementation.

CTF Frontline Staff
Administrative staff, providers (within and outside the organization) who will carry out the intervention or be affected by it.

CTF Integrators
Individuals who build relationships between organizations and create linkages to facilitate the intervention.

CTF Patients, Caregivers, and Other Stakeholders
Patient and his/her family members, and members of the family's support network. B Engaging: Attracting and involving appropriate individuals in the implementation and use of the intervention through a combined strategy of social marketing, education, role modeling, training, and other similar activities.

B.1 Opinion Leaders
Individuals in an organization who have formal or informal influence on the attitudes and beliefs of their colleagues with respect to implementing the intervention.

B.2 Formally Appointed Internal Implementation Leaders
Individuals from within the organization who have been formally appointed with responsibility for implementing an intervention as coordinator, project manager, team leader, or other similar role.

B.3 Champions
"Individuals who dedicate themselves to supporting, marketing, and 'driving through' an [implementation]", overcoming indifference or resistance that the intervention may provoke in an organization.

B.4 External Change Agents
Individuals who are affiliated with an outside entity who formally influence or facilitate intervention decisions in a desirable direction.

B.5 Key Stakeholders*
Individuals from within the organization that are directly impacted by the innovation, e.g., staff responsible for making referrals to a new program or using a new work process.

B.6 Innovation Participants*
Individuals served by the organization that participate in the innovation, e.g., patients in a prevention program in a hospital.

CTF Engaging Organizations, External Context
Developing and capitalizing on relationships with providers, leaders, and frontline staff in the implementing organizations, and to external providers, resources, funders. C Executing: Carrying out or accomplishing the implementation according to plan.

CTF Decisionmaking
Frequency, duration, and timing of the activities involved in making decisions. The directionality of these activities.

CTF Staging and Iteration
Degree to which the care transition is carried out in iterative, incremental steps or implemented in its entirety within a specified period.

D Reflecting & Evaluating:
Quantitative and qualitative feedback about the progress and quality of implementation accompanied with regular personal and team debriefing about progress and experience.

CTF Measurement Capability and Data Availability
Availability of timely data. Capacity for monitoring, evaluation, and process improvement. Includes measurement differences; accountability for collection, documentation, and analysis.