Table 3.

Summary of Takeaways from Key Informant Interviews

What worked well

1. Multidisciplinary collaboration • Relationships and communication with providers from primary care, specialty care, and a variety of disciplines (e.g., social work) “Patients had issues that crossed medical, behavioral, and social domains, so it was critical to have experts in these areas on the team” • Collaboration approaches varied (e.g., outreach calls, email, and in-person meetings) 2. Dedicated staff for intervention • Important for ensuring continuity of care, timely changes in management, and developing trust with patient and family “It made a difference that [there was a] dedicated person to respond to alerts, contact physicians to facilitate interactions, etc.) …[C]are suggestions…were quickly implemented” “The fact that we had the same nurse following the patient…was viewed by patients and family caregivers as really central…” 3. Knowledge of and relationship with community-based services • Services included transportation, food banks, home-delivered meals, and substance abuse treatment “Establishing a vast network of relationships [with community organizations] was important … to effectively help patients” 4. Staff key qualities and skills • Dedication and compassion, communication and relationship-building skills

Challenges and sustainability

1. Difficulty of impacting readmissions • Timeframe for metrics is too short, and there are often many challenging factors to address “30 days doesn’t give you sufficient time…especially in elderly patients with many issues… Everything that could be possibly going wrong is going wrong…” 2. Adaptation of interventions • Modified over time to meet changing priorities (e.g., adaptation for different high-risk populations) • Certain components or techniques selected for adoption by sites, while others were not 3. Stakeholder engagement and financial viability • Engagement with senior leadership as key to sustainability “[P]artnership between the architects of these models and the health systems, …strong collaboration…is required to meaningfully move evidence into health systems…” • Difficulty in determining which group (within health system) benefits most and should bear financial responsibility for staffing, etc.