Patient-level barriers, related facilitators, and proposed strategies for timely home health care and outpatient appointments for sepsis survivors: Perspectives from healthcare system and home health care informants

Abstract

Objective:

This study explored the perspectives of healthcare system and home health care (HHC) informants — including leaders, managers, clinicians, sepsis coordinators, and care coordinators — on patient-level barriers, related facilitators, and proposed strategies related to timely HHC nursing visits and outpatient appointments among sepsis survivors. This work is part of a larger qualitative needs assessment within Improving TRansitions ANd outcomeS oF sEpsis suRvivors (I-TRANSFER), which aims to implement a sepsis survivor hospital-to-home care transition protocol across five healthcare system-affiliated HHC agency dyads.

Methods:

Semi-structured interviews informed by the Consolidated Framework for Implementing Research were conducted with informants as part of the I-TRANSFER qualitative needs assessment. Interviews were analyzed via a deductive-inductive coding approach, resulting in 32 themes and subthemes. A targeted query was done to extract data from themes and subthemes relevant to patient engagement in follow-up care.

Results:

Sixty-one interviews were conducted with 91 informants. The four themes included Patient Behaviors, Decisions, and Preferences; Care Coordination; Patient Education; and Access to Care. Patient-level barriers include refusal or delay of HHC, missed outpatient appointments, scheduling difficulties, low health literacy, language barriers, competing health priorities, transportation issues, financial difficulties, and not having an outpatient provider. Facilitators and proposed strategies include proactive patient education, building clinician-patient trust, leveraging technology, implementing dedicated scheduler and sepsis patient education roles, building population health programs, and partnering with community organizations.

Conclusion:

Findings highlight common challenges and offer actionable strategies to engage sepsis survivors in their follow-up care. They have important implications for patient education delivery, discharge planning, social determinants of health, and technology to enhance hospital-to-home care transitions.

Practice Implications:

Recommendations include hiring dedicated schedulers, early screening for patient learning barriers, expanding sepsis coordinator roles, using telehealth and text-messaging, and strengthening community partnerships.

1. Introduction

Adult patients discharged from hospital to home are vulnerable to adverse health events, including high morbidity and readmission [1–4]. Sepsis survivors are particularly at risk for hospital readmission because they experience long-term sequelae, including functional limitations, cognitive impairment, new or recurring infection, chronic disease exacerbation, dyspnea, diminished organ function, and lethargy [5–8]. A meta-analysis estimated that around one in five sepsis survivors will be readmitted within 30 days, comparable to patients with heart failure or myocardial infarction [9]. Close monitoring in the early post-discharge period is critical because among those readmitted, one-third of the readmissions occur within the first seven days after discharge [10].

Prior research indicates that early post-discharge follow-up is effective in preventing readmissions [11–14]. Studies examining electronic health records within healthcare systems found that adult patients who attended an outpatient appointment within seven days post-discharge were less likely to be readmitted within 30 days compared to those who did not [11,12]. Among recently discharged adults in home health care (HHC), those who did not receive an initial nursing visit within two days after hospital discharge had a 12 % higher odds of 30-day readmission than those who did [14]. In a comparative effectiveness study involving United States (U.S.) Medicare claims data from 170,571 sepsis survivors, Deb et al. [13]found that early follow-up care — defined as an initial HHC nursing visit within two days, a second HHC nursing visit, and an outpatient appointment within seven days post-discharge — led to a 41 % relative reduction in 30-day readmissions compared to those who did not receive this care.

This study is part of a larger qualitative needs assessment for a type-1 hybrid effectiveness-implementation science study entitled Improving TRansitions ANd outcomeS oF sEpsis suRvivors (I-TRANSFER) [15], which aims to measure the implementation and effectiveness of the evidenced-based sepsis survivor hospital-to-home health and outpatient care transition protocol informed by Deb et al. [13] I-TRANSFER involves healthcare systems, which include hospitals and outpatient services, and selected affiliated HHC agencies [15]. The protocol aims to achieve eight objectives: 1) identify sepsis survivors during their hospitalization, 2) identify sepsis patients for HHC referral, 3) send referrals to HHC agencies, 4) facilitate healthcare system-HHC information exchange, 5) schedule an outpatient appointment to occur within seven days post-discharge, 6) complete the first HHC nursing visit within two days post-discharge, 7) provide a second HHC visit within seven days post-discharge, and 8) promote HHC facilitation of outpatient appointments [15].

The I-TRANSFER qualitative needs assessment provided a unique opportunity to identify patient-level barriers — as reported by healthcare system and HHC informants — and potential strategies towards promoting timely receipt of HHC nursing visits and outpatient appointments [15]. Previous studies [16–20] with patients have identified several patient-level barriers to early post-discharge follow-up care, including negative experiences with post-acute care, forgetfulness, transportation difficulties, as well as privacy and cost concerns. However, insights from healthcare system and HHC informants are equally important as they may influence patient decision-making, healthcare delivery, and resource allocation. Furthermore, gathering their perspectives on facilitators and proposed strategies may inform targeted approaches to address such barriers. Therefore, the objective of this study is to describe patient-level barriers, facilitators, and proposed strategies to promote timely HHC nursing visits and outpatient appointments following hospital discharge of sepsis survivors. These findings may inform the implementation of sepsis survivor care transition protocols, including I-TRANSFER [15].

2. Methods

2.1. Overview

Five U.S. healthcare system-HHC agency dyads, diverse in size, teaching status, geographic region, and HHC ownership status, were purposefully selected to participate in I-TRANSFER [15]. The Institutional Review Boards (IRBs) of the University of Pennsylvania and VNS Health approved this study. The IRBs of the other sites reviewed the protocol and granted permission after determining there was “no research engagement” of their patients or by their staff.

The analyses presented here draws from the I-TRANSFER qualitative needs assessment [15], and a qualitative descriptive design [21] was used to provide a rich description of the informants’ perspectives while staying close to the data. Findings for this study are reported in accordance with the COnsolidated criteria for REporting Qualitative research (COREQ) checklist (Supplemental File 1) [22].

2.2. Participants and Data Collection

Each healthcare system-HHC agency dyad formed site implementation teams consisting of informants committed to implementing the I-TRANSFER care transition protocol [15]. These informants were purposively sampled based on their involvement in care transitions for sepsis survivors and included mostly healthcare system and HHC leaders but also clinicians, care coordinators, quality personnel, and nurse or care coordinator managers. Leaders were those who oversaw quality, administration, and clinical aspects of care. Clinicians included nurses, physical and occupational therapists, and providers (i.e. physicians, hospitalists, intensivists, physician assistants, and nurse practitioners). Care coordinators were based in healthcare systems and worked in either outpatient or inpatient settings. To describe site characteristics, descriptive data on each healthcare system-HHC agency dyad was extracted from a Medicare Provider of Service File obtained as part of I-TRANSFER [15].

Pre-implementation needs assessment interviews with individual or groups of informants were conducted from May to November 2021, with one additional interview in June 2022, using a semi-structured interview guide (available in O’Connor et al. [15]) informed by the I-TRANSFER objectives and the Consolidated Framework for Implementation Research (CFIR) [23]. This framework is widely used within implementation science to identify and assess implementation determinants across five domains [23]. Implementation determinants include barriers, facilitators, and proposed strategies, while CFIR domains include innovation (intervention characteristics), inner setting (organizational culture and characteristics), outer setting (external influences), individuals (those involved in the implementation and their perceptions), and implementation process (workflows and strategies to facilitate implementation) [23]. All pre-implementation needs assessment interview questions covered the five CFIR domains.

Interviews focused on exploring barriers, facilitators, and proposed strategies towards implementing the care transition protocol for sepsis survivors [15] and were led by KHB, MAS, and MOC, all of whom are Ph. D. prepared nurses with expertise in care transition, the care of sepsis survivors, qualitative research, and/or HHC nursing. Snowball sampling was used to identify additional informants until data saturation was reached. Each interview was hosted, recorded, and transcribed verbatim via Zoom^®. Transcripts were cleaned by trained research assistants, reviewed for quality, and uploaded onto NVivo version 14 [24], a qualitative data management software, for data analysis.

2.3. Data Analysis

Coding was conducted by five coders (ES, KBH, MAS, MOC, and SO). MGT (see acknowledgements) also assisted in the coding process early in the data analysis phase. We initially coded deductively for barriers, facilitators, and strategies for each of the eight I-TRANSFER objectives, followed by inductive coding to generate themes and subthemes. To ensure high inter-rater reliability among the coders, weekly meetings were held to resolve coding discrepancies and update the codebook, until the percent-agreement reached at least 90 %. Trustworthiness was maintained via an audit trail, investigator triangulation, and member checking [25,26]. The coding process resulted in a total of 32 themes and subthemes.

For this analysis, a query was conducted in NVivo^® to extract data coded under specific themes and subthemes relevant to patient engagement in HHC nursing visits and outpatient appointments, as defined in the codebook. The query used a Boolean OR operator to include the relevant themes and subthemes presented in the results section below. The five coders reviewed the extracted data and their interpretations together, coming to a consensus on the specific data to include under each theme and subtheme in the results.

3. Results

A total of 36 individual and 25 group interviews were conducted with 91 informants from the five-healthcare system-HHC agency dyads. Among these informants, 57 were from healthcare systems and 34 were from HHC agencies. Nine clinicians, nine care coordinators, 14 managers of nurses or care coordinators, two quality personnel, four sepsis coordinators, and 53 leaders (seven administrative, 13 quality, and 33 clinical) were interviewed. Table 1 below provides information on each of the five-healthcare system-HHC dyads.

Table 1:

Characteristics of Healthcare System-Home Health Care (HHC) Agency Dyads

Dyad	Teaching Status	Size	U.S. Geographic Region	HHC Ownership	Hospital to HHC Ratio
1	Academic	Large	East	Hospital-Owned	6:1
2	Community	Medium	East	Hospital-Owned	4:1
3	Community	Small	West	Hospital-Owned	3:1
4	Academic	Large	East	Free-Standing	2:1
5	Academic	Large	West	Free-Standing	1:1

Four themes and six subthemes (indicated in parentheses) from the I-TRANSFER qualitative needs assessment were selected for this study: Patient Behaviors, Decisions and Preferences (Refuse or Delay HHC and No-Show Outpatient); Care coordination (Scheduling); Patient education; and Access to care (Transportation, Financial-Insurance, and No Outpatient Provider). Fig. 1 below shows the relationships between the themes and subthemes, and Table 2 contain exemplary quotes for themes and subthemes.

Fig. 1. Themes and Subthemes.

Table 2:

Themes, Subthemes, and Supporting Quotes

Themes	Subthemes	Supporting Quotes
Patient Behaviors, Decisions, and Preferences	Refuse or Delay HHC	Barrier: “We frequently see patients who don’t feel like they need home health. Don’t want to have a stranger coming into their home.” (Healthcare System Care Coordinator Manager, Dyad 5)
		Facilitator: “Yes, so actually on our first intake, even if a patient has not accepted home care in the hospital, we will review that with them and ask them to reconsider home care. And a lot of times you know, not a lot of times, the people who did not accept home care in the hospital will realize that when they get home that they need that home care, and so they will be more amenable to getting home care in.” (Healthcare System Informant, Dyad 2)
		Proposed Strategy: “Trust is the key. I think not only trust in letting us into their home but trust in hearing how they got to this point in their journey.” (HHC Informant, Dyad 3)
	No-Show Outpatient	Barrier: “Sometimes we do get on the phone, and you know, the patients will say, you know, ‘My friend, my daughter, my husband, whoever, was supposed to drive me but they're at work. I don’t know how I'm going to get there,” right, and the appointment does, you know, get changed or cancelled.” (Healthcare System Informant, Dyad 4)
		Facilitator: “There is a reminder, probably within 24 hours, 24 to 48 prior to the appointment, just be like, ‘Hey, you know, you're one of our target patients, and you need to really go to this appointment.’” (Healthcare System Informant, Dyad 3)
Care Coordination	N/A	Proposed Strategy: “So, I think if we're on the units, we will have even more opportunity to have more face time with our patients and have that opportunity to go back and reintroduce. I think my team just recognizes that depending where you're meeting the patient that day, it just may not be a good day for one more discussion about something else they have to think about. So, not necessarily saying ‘Okay, you don’t want home care, fine goodbye’ and not revisiting [but instead] just kind of saying ‘You know what, let’s just think about it. You're not going anywhere today or tomorrow. I'll just circle back, and we'll talk about it again.’ And I think they find most patients are like, you know, ‘I like that plan’, and they're more open to considering. I think we secure home care more often if we do that.” (Healthcare System Informant, Dyad 1)
	Scheduling	Barrier: “A lot of our patients don’t have, sort of, the wherewithal to make their own appointment or to know their schedule, and in terms of when to follow up.” (Healthcare System Informant, Dyad 3)
		Facilitator: “I have a team of nurses who make post-discharge calls for patients … and we are reviewing with them—their discharge instructions, ensuring that they have post discharge follow up, whatever follow ups are indicated on their patient after visit summary that they receive from the hospital. We're ensuring that they have those appointments scheduled, helping to schedule those if they're not scheduled, and confirming home care services—that they received them, that they've been contacted.” (Healthcare System Informant, Dyad 4)
		Proposed Strategy: “Ideally, if we could have a centralized way to do this [scheduling outpatient appointments], it would be lovely.” (Healthcare System Informant, Dyad 1)
Patient Education	N/A	Barrier: “If you're uneducated and you're hard of hearing and you have a million other problems, does it matter that you have sepsis and is that, you know, just an additional diagnosis and how serious do I take it?” (HHC Informant, Dyad 5)
		Facilitator: “I have been um trying to empower my teams to include the families early on. So, if there's any teaching that needs to be done, you know, bring in the family, bring in the daughter, teach them, ‘You need to be watching daily weights. You would be watching your diet. Make sure they make their appointments. Make sure that you know that they have the right food in the home at all times.’” (Healthcare System Informant, Dyad 1)
		Proposed Strategy: “I think education needs to start at the bedside. Right, it can’t start at home. Education needs to be started at the bedside and then continue, you know, at home because everybody's got to be messaging the same thing.” (HHC Informant, Dyad 4)
Access to Care	Transportation	Barrier: “And a lot of patients are really, homebound they can’t get out of the house, and they might not have caregivers that can take them to an appointment in the middle of the workday.” (HHC Informant, Dyad 2)
		Facilitator: “We also have a contract with them for a program called courtesy transport where they have sedans that they will take patients home from the hospital, but they will also take patients to appointments. So, if a patient has a transportation issue, not always, but a lot of times, the paramedic can arrange transportation for them to get there through their program that we pay for. Again, we pay for it.” (Healthcare System Informant, Dyad 1)
		Facilitator: “If they, if it’s a Tele-health visit, certainly, we're happy to plan our visit around the timing of the Tele-health visit so that you know they could use our smartphones or tablets to make the Tele-health happen if we need to. We did find some seniors don’t have capabilities to do Tele-health from their phones, or they don’t have Internet and so we have been doing that. It doesn’t have to be a nurse who is there, it can be our physical therapist, occupational therapist right? The speech therapist, the social worker, I mean whoever’s there for the visit that day can help with Tele-health.” (HHC Informant, Dyad 5)
	Financial-Insurance	Barrier: “There's a lot of other factors like insurance, socioeconomic status. So, like a patient can barely afford their groceries, expecting them to pay for an uber to go to doctor's appointments because they don’t have a car that could be a serious financial burden for them. Um, finances are a big issue for our section of the city, so that could be a definite problem.” (HHC Informant, Dyad 1)
		Facilitator: “If it’s a private insurance patient who just doesn’t have one [outpatient provider], we’ll often use the insurance website. Or sometimes, patients have an idea, like their sister goes somewhere and we'll see if they're taking new patients. So yeah, kind of a combination of the internet, the patient, and just calling places to see if they are still taking patients.” (Healthcare System Informant, Dyad 5)
	No Outpatient Provider	Barrier: “Some patients- we’ll get patients who have never seen a provider. Some patients, we’ll get patients who just feel like they haven’t had a need to see a provider, or they've moved to the area to be close to family so then they're- they're in between providers. Like maybe they are coming from another state, and they haven’t had time to find a new provider.” (Healthcare System Informant, Dyad 1)
		Facilitator: “In our discharge clinic, we see the patients that are from our clinic, primary care patients. We cover for other clinicians within group and then we see patients that have not had an identified primary care doctor. So, it’s us and we also have the community health centers, and they take a lot of no doc patients as well. But like a third to half of the patients we see in our discharge clinic had previously not had primary care docs, and then probably 75% of those end up establishing with us for primary care.” (Healthcare System Informant, Dyad 3)

3.1. Patient Behaviors, Decisions, and Preferences

Healthcare system and HHC informants described challenges in engaging patients with HHC nursing visits and outpatient appointments, noting a broader mismatch between healthcare professionals’ expectations and patients’ behaviors, decisions, and preferences for follow-up care. These patterns, along with related facilitators and proposed strategies, were categorized into either the Refuse or Delay HHC or No-Show Outpatient subthemes.

3.1.1. Subtheme: Refuse or Delay HHC

Healthcare system and HHC informants noted that patients’ refusal or delay of HHC nursing visits appeared to be influenced by psychosocial factors, logistical challenges, patient engagement barriers, and contextual influences. According to these informants, psychosocial factors reflected broader trust dynamics between patients and healthcare professionals and included patients’ preferences to be cared for by family caregivers over trained professionals, privacy concerns, previous negative experiences with HHC, and fears of legal repercussions for housing undocumented immigrants. Logistical challenges included patients having multiple outpatient appointments within the first week post-discharge, leading to delayed initiation of HHC nursing visits. Meanwhile, informants observed that patient engagement barriers include patient delays in confirming HHC visits after initially accepting them, and patients being absent upon HHC clinician arrival. Contextual influences mentioned by informants include patients’ expressed desire to recuperate from their hospitalization before receiving HHC nursing visits and their decision to stay with another family member instead of returning home after discharge, making it difficult for HHC nurses to find them.

Informants also identified facilitators and proposed strategies to patient engagement with HHC. Facilitators included adapting HHC nursing visits to accommodate patients’ preferences and availability, proactive patient education to emphasize the benefits of HHC nursing visits and involving families in the HHC decision-making process. Meanwhile, proposed strategies include building clinician-patient relationships grounded in trust.

3.1.2. Subtheme: No-Show Outpatient

Healthcare system and HHC informants reported barriers to missed outpatient appointments that were associated with lack of transportation and patient engagement factors, including forgetfulness, appointment declinations, and feeling unwell. Facilitators to improve attendance include proactive reminders from visiting HHC nurses and alternative communication approaches from outpatient services, such as phone calls, emails, and text messages.

3.2. Care Coordination

Healthcare system and HHC informants emphasized care coordination as essential for facilitating smooth care transitions from hospital to HHC and outpatient care. As such, one informant proposed promoting early patient engagement in follow-up care planning to facilitate patients’ acceptance of post-discharge HHC nursing visits and outpatient appointments.

3.2.1. Subtheme: Scheduling

Healthcare system informants identified patient-related scheduling challenges as a key barrier to care coordination, reflecting gaps in care continuity, logistical planning, and patient engagement. Informants reported patient-level barriers include uncertainty about availability, patient decision to self-manage instead of seeking a new provider when their regular provider is unavailable, difficulties navigating the outpatient appointment scheduling system, and lack of responsiveness to outreach efforts regarding outpatient scheduling.

To resolve these gaps, healthcare system informants described facilitators and proposed strategies to improve scheduling coordination and accessibility. Facilitators include offering direct scheduling support, while proposed strategies consist of reaching patients via alternative communication approaches (text messaging), hiring dedicated schedulers, streamlining scheduling workflows, and implementing structured inpatient-outpatient care coordinator handoffs. However, informants expressed concerns regarding the long-term scalability of dedicated scheduler roles, sharing that previous attempts within healthcare systems were disrupted due to financial and COVID-19 pandemic-related challenges.

3.3. Patient Education

Healthcare system and HHC informants considered health literacy, language barriers, and competing health priorities as barriers to sepsis patient education. Informants highlighted the involvement of informal caregivers and the use of structured patient education resources (such as information sheets and videos) as key facilitators to improving patient education delivery and comprehension. They also stressed the need for consistent patient education across the care continuum from hospital to home. One healthcare system informant proposed a system-wide approach by designating sepsis patient educators tasked with educating sepsis survivors about their diagnosis and need for follow-up care. While informants noted that one healthcare system already has sepsis coordinators and clinical nurse specialists for this role, staffing constraints limit scalability as the large number of sepsis survivors exceeds their capacity.

3.4. Access to Care

Healthcare system and HHC informants identified social determinants of health and patient-specific characteristics as barriers to patients accessing follow-up care. These barriers, along with related facilitators and proposed strategies, belonged to the following three subthemes: Transportation, Financial-Insurance, and No Outpatient Provider.

3.4.1. Subtheme: Transportation

According to informants, patient-level transportation barriers to outpatient appointments stemmed from patient physical impairment and caregiver unavailability. To address such barriers, informants highlighted transportation assistance programs and alternative outpatient appointment formats, namely home visiting providers and telemedicine. However, informants shared that patients with poor technology literacy, complex health conditions, and/or limited internet access may have trouble accessing telemedicine, underscoring disparities in digital healthcare access. To improve telemedicine accessibility, HHC informants proposed aligning HHC visits around patients’ telemedicine appointments, allowing HHC clinicians to be present to assist with technology troubleshooting when needed.

3.4.2. Subtheme: Financial-Insurance

Informants identified financial and insurance patient-level barriers as key social determinants of health factors affecting patients’ ability to prioritize and afford follow-up care. Patients with financial limitations must prioritize immediate needs, such as food and housing, over HHC nursing visits and outpatient appointments. Informants from one healthcare system described a population health program, where social workers assist patients with financial difficulties in scheduling outpatient appointments, coordinating transportation, and accessing medication, but these services are limited relative to the larger target population. They also noted that patients on Medicaid may experience challenges accessing outpatient appointments as some outpatient providers do not accept this type of health insurance. Thus, informants proposed leveraging technology solutions to identify Medicaid-accepting providers.

3.4.3. Subtheme: No Outpatient Provider

Informants reported that some patients are not established with an outpatient provider, preventing access to timely outpatient appointments and continuity of care. Informants shared that some patients reported not having an outpatient provider due to a lack of perceived need, time constraints, being uninsured, or having recently relocated to the area. Healthcare system informants described transitional care facilitators, including having inpatient coordinators leverage insurance websites and patients’ personal connections to find providers, utilizing providers with dual inpatient-outpatient roles to follow patients after discharge, and partnering with discharge clinics or community health centers.

4. Discussion and conclusion

4.1. Discussion

This study identified four themes and six subthemes related to patient-level barriers, facilitators, and proposed strategies for timely HHC nursing visits and outpatient appointments among sepsis survivors, according to the perspectives of healthcare system and HHC informants. While some barriers, such as lack of transportation, financial difficulties, and privacy concerns, align with those from previous research [16–18], this study also uncovered strategies to overcome such challenges and promote patient engagement with follow-up care. These include having dedicated patient educators and schedulers, proactive communication with patients and informal caregivers on follow-up care, leveraging partnerships with transportation services and community health centers, and utilizing technology such as text messaging and telemedicine. The findings have important implications for the care of sepsis survivors throughout the hospital-to-home care continuum, particularly in the areas related to patient education delivery, discharge planning, social determinants of health, and technology.

Informants identified health literacy, language barriers, and complex health conditions as barriers preventing sepsis survivors from understanding the severity of their diagnosis and the necessity of follow-up care. Although there may be several education resource options, early assessment of patients’ learning barriers and preferences is needed to customize patient education throughout the care continuum. Healthcare professionals, such as nurses and providers (physician and advance practice providers), play a role in delivering patient education, but time and staffing constraints within hospital settings may prevent them from prioritizing individualized patient education amidst other competing patient care demands [27–30]. Given sepsis coordinators’ role in improving hospital sepsis patient care and reducing sepsis survivor readmissions [31], healthcare system leaders may consider expanding their responsibilities to include the delivery of personalized sepsis education, focused on diagnosis, post-hospitalization recovery, and management of long-term sequelae, to sepsis survivors. As not all healthcare systems may have sepsis coordinators, research showing the potential value of their role in improving sepsis survivor health outcomes is needed to justify creating such positions.

Several studies [32–35] shared that patients, including sepsis survivors [33], feel unprepared to manage their care after discharge, and Horwitz et al. [36] found that 30 % of patients in an academic medical center received less than a day’s notice before discharge. These findings may suggest that patients may be discharged without adequate time to prepare for and understand their follow-up care expectations. Informants proposed initiating discharge planning early during hospitalization to allow for sufficient time to communicate the importance of, and coordinate, HHC nursing visits and outpatient appointments with patients. Clinical decision support systems for discharge planning may identify those potentially benefiting from such follow-up care, allowing for early anticipation and introduction of follow-up care [37]. However, most of these systems have yet to be widely implemented within the busy hospital setting [38]. Additionally, some informants shared that their healthcare systems previously had dedicated personnel engage with sepsis survivors and families to understand their availability and preferences when scheduling HHC nursing visits and outpatient appointments, but these roles were eliminated due to budget cuts and COVID-19. Thus, future studies may consider 1) developing effective strategies to support the implementation of discharge planning clinical decision support systems and 2) evaluating whether dedicated personnel enhance patient participation in timely follow-up care and contributes to better health outcomes.

Social determinants of health, such as food and housing insecurity, financial difficulties, and lack of transportation, may impact a patient’s ability to access and/or afford HHC nursing visits and outpatient appointments. According to the Affordable Care Act, non-profit healthcare systems must engage with their local communities to address unmet health-related social needs, which are individual-level effects of broader social determinants of health [39,40]. A recent scoping review by Rangachari et al. [40] found that many healthcare systems fulfill this requirement through downstream approaches, including building population health programs and facilitating partnerships with transportation services and community health centers — all of which were identified by informants as facilitators and proposed strategies to improve access to care. However, informants shared concerns regarding the scalability of such programs and partnerships to the larger community, reflecting broader challenges in sustaining such approaches. To complement such downstream efforts, healthcare systems and HHC agencies may also consider implementing upstream approaches, such as investing in affordable housing projects and community-based health education programs, to address structural barriers limiting access to follow-up care after hospital discharge [39,40]. A combined downstream and upstream approach may not only improve access to follow-up care for individual patients but also enhance the sustainability and equity of such healthcare delivery through addressing underlying structural factors contributing to social determinants of health.

According to informants, outpatient appointments may be facilitated via telemedicine, appointment reminders may occur over phone calls, emails, and text messages, and patient education may be delivered virtually. Other technology modalities for patient education delivery include mobile applications [41–44] and patient portals [45]. However, technology relies on internet or cellular connections, both of which are poor in rural and underserved communities [46,47], and some patients may have low digital literacy or lack necessary equipment. Thus, health policy makers may consider classifying technology access, digital literacy, and weak internet or cellular connectivity as social determinants of health, encouraging others to work towards improving such barriers [48,49]. In addition, community organizations may consider developing programs to either provide patients with technology or improve their digital literacy.

4.2. Strengths and Limitations

Our study has notable strengths. For instance, interviewing a large sample of informants across various positions, geographic locations, and healthcare settings allowed us to gather comprehensive data on identified patient-level barriers, along with related facilitators and proposed strategies, towards facilitating timely HHC nursing visits and outpatient appointments for sepsis survivors. In addition, informants may provide broader perspectives than those provided by patients as they speak to their experiences with many patients.

However, study findings must be interpreted with caution. First, convenience sampling approaches and having an unequal number of informants per dyad may skew our findings and introduce potential biases. Facilitators and proposed strategies shared by informants may not necessarily work for or apply to all healthcare systems and HHC agencies. Furthermore, informants’ perspectives on patient-level barriers may differ from those from patients, as they may be shaped by professional roles, healthcare system workflows, and subjective experiences with patient care. Thus, such barriers may be from a healthcare delivery perspective instead of from the patients’ own experiences. Interactions between informants and patients are limited to that within healthcare system and HHC settings, limiting informants’ ability to capture patient-level barriers extending beyond the clinical environments. Future studies should directly engage with sepsis survivors to gain a comprehensive understanding of their barriers to receiving timely HHC nursing visits and outpatient appointments.

4.3. Conclusions

By capturing the perspectives of healthcare system and HHC informants, this study shows how patient-level barriers to follow-up care are perceived within healthcare settings and offers actionable strategies to support timely HHC nursing visits and outpatient appointments among sepsis survivors. Findings may lay the groundwork for future interventions aimed at improving care transitions and health outcomes within this at-risk population. Researchers, along with healthcare system and HHC leaders, may consider evaluating the feasibility, sustainability, and effectiveness of these strategies to facilitate patient engagement and acceptance of timely follow-up care.

Furthermore, study insights may lead to health policy implications (e.g. classifying weak internet connectivity as a social determinant of health [48,49]), targeted approaches (e.g. combining upstream and downstream approaches to improve access to follow-up care, expanding the role of sepsis coordinators, and engaging community organizations to familiarize patients with technology), and future research directions (e.g. evaluating the effectiveness of strategies towards implementing discharge planning clinical decision support systems). Together, these insights and strategies may advance efforts to improve sepsis survivor care across the hospital-to-home continuum.

4.4. Practice Implications

Healthcare system and HHC leaders may consider hiring dedicated schedulers to engage patients and families to coordinate HHC nursing visits and outpatient appointments prior to hospital discharge. Building and strengthening relationships with community organizations, such as community health centers and federally qualified health centers, may also facilitate patient access to follow-up care. Technology may be leveraged to remind patients of their outpatient appointments and to facilitate telemedicine visits.

Early screening for learning barriers, such as low health literacy and language barriers, may support patient education customization in accordance with the patients’ needs, their comprehension level, and their preferences. Patient education is crucial for sepsis survivors’ understanding on the importance of receiving timely follow-up care. Therefore, sepsis coordinators may play a key role in educating sepsis survivors on the seriousness of their diagnosis and encouraging their engagement with HHC and outpatient services.

Supplementary Material

Appendix A. Supporting information

Supplementary data associated with this article can be found in the online version at doi:10.1016/j.pec.2025.109207.