Table 4.

Redesigning the transitional process.

Sub-theme	Barriers	Strategies	Example Clinical Team Member Quotes
Complicated transitional processes	- Information load to patient - Multiple clinical team members - Role ambiguity	- Coordinating clinical efforts - Integrating multiple levels of care into the standard of care - Clarity of clinical roles - Having a transitional guide present	“We go over their discharge summary… When they get home, we call them. We go over their medication. We help them with resources and appointments. And most of the times we try to meet the patient while they’re in the hospital … Because sometimes patients don’t want us calling them right away, 24 hours after their discharge, because they don’t know how they feel. They just got home and they’re like, “Give me time to get settled and get back home and get myself organized.” (Transition Nurse)
Inadequate home team, including professional support	- Patient not wanting others in home - Scattered information and medications -Misinformation - Poly-pharmacy	- Clinical staff in home to assess situation and provide face-to-face instruction - Integrating multiple levels of care into SOC - Clarity of clinical roles	“Because some patients won’t – refuse. They refused skilled nursing and they don’t want anyone in their home. So I have to do everything by phone. I’ve been on the phone with a patient for two and a half hours. They were on 25 medications. It was very difficult and I was just kind of pleading with them, “It would be easier and would limit mistakes, if I could just be there to help you.” … And I had to walk through and they had medications that wasn’t on our discharge summary, so I had to write all those down …” (Transition Nurse)
Gaps in logistics	- Too many people, of differing roles, making un-coordinated decisions - Time - Inter-team communication	- Streamlining the process - Coordination of tasks	“The time of the doctors, like especially – for example, patient has 10, 20 medications. The nurses, they don't have really time. You will see if you will audit not all patient is done the [medication reconciliation], or sometimes the patient doesn't know and the family doesn't know or they're not a [hospital] patient, so they won't know.” (Discharge Nurse) “Communication, time needed to do correct communication. Time is a big problem.” (Case Manager)