Table 1.
Description of the Four Transitional Care Interventions (TCIs)
| Description | Case A: Intermediate care center | Case B: Envelope action/medication reconciliation | Case C: Caring neighborhood teams | Case D: Chronic heart failure care program |
|---|---|---|---|---|
| Overview | An interim center referred to as “bed house” is developed inside a hospital―initiated during the outbreak of the COVID-19 pandemic. It is a care transition unit between hospital and home settings and vice versa. Implementation started in April 2020 and lasted for approximately 3 months (first wave of COVID-19). | An envelope that contains the patient’s medication scheme and prescriptions is provided to patients upon discharge from hospital and addressed to the community pharmacist. Implementation started in 2018.a | A network of multidisciplinary primary care providers and social workers within one neighborhood, that work jointly on improving care at the population level. The teams focused on mapping the chronically ill and vulnerable individuals with multimorbidity within the neighborhood and providing care coordination tailored to their needs. Implementation started in 2018.a | A care program developed specifically for heart failure disease management and care coordination. Implementation started in 2018.a |
| Function | To prevent hospital bed-blocking by accommodating patients that are either medically stable to be discharged from hospital but not yet able to return to their home due to social and medical reasons, or have care needs which were too complex to be able to stay at home but did not require hospitalization. | To facilitate medical information transfer between hospital care and the community pharmacist in order to perform medication reconciliation (checking for medication discrepancies and medication-related issues) and patient counseling. | To ensure integrated and population-oriented care at the neighborhood level. | To ensure a close follow-up for the chronic heart failure patients discharged from the hospital. |
| Transitional care aim | Improve care transitions from hospital to home and vice versa. | Improve care transitions from hospital to home or community settings and prevent rehospitalization. | Prevent care transitions from home or community settings to hospital and reduce readmissions. | Improve care transitions from hospital to home and avoid rehospitalization. |
| Settings and care organizations involved | Hospital, intermediate care unit in the hospital, private home, homecare, and primary care. | Hospital, community pharmacists’ providers’ network, homecare, and primary care. | Community service centers, social care, homecare, and primary care. | Hospital, community, private home, homecare, and primary care. |
| Other features | Use of the “Siilo application,” a digital communication tool developed and used among care providers within the center and outside, which enabled continuous communication flow to arrange care. | Home care nurse–role as heart failure patient educator Structured transitional protocol to guide postdischarge care Development of a discharge checklist in the hospital’s EHR specific for heart failure postdischarge follow-up care E-learning course for GPs on heart failure management Automated diagnostic and qualitative audits in GPs’ EHR to improve chronic heart failure case finding |
Notes: COVID-19 = coronavirus disease 2019; EHR = electronic health record; GP = general practitioner.
aThe development and implementation of the TCIs were initiated in 2018 and continued until at least 2021 when this study was conducted. All four interventions were coordinated by a core team of project coordinators from within the different organizations involved across the interventions in the region and not one primary organization per intervention.