Lessons Learned

Experience, Learn, Share

A main focus of the Transitional Care Evidence to Action Network (TC-E2AN) is collaboration among researchers, patients, caregivers, and other stakeholders, who meet to discuss challenges, opportunities, and lessons learned.

Here are some of those lessons, based on network members’ experiences in two focus areas: Transitional Care Research and Transitional Care Service Delivery

Lessons in Transitional Care Research

Balancing Flexibility and Fidelity in Pragmatic Trials

Think about how to monitor intervention fidelity early in the planning of pragmatic trials and expect to adapt the process along the way.

Engaging Community Partners in Research Studies

Exploring the concept of engagement in creative ways helps researchers and community partners define a shared vision for engagement in research.

Engaging Patient Partners throughout the Research Process

To develop and refine a patient-centered intervention, assemble an autonomous group of patients and stakeholders and ask yourself whose voice is still missing.

Assessing Resources Required to Deliver TC Interventions

For a comprehensive assessment of a transitional care intervention, purposefully plan for and systematically document the resources required to implement the program.

Using Research Findings to Make an Impact on Policy

To help make research findings actionable, begin planning early and engage patient partners and other stakeholders in the process.

Optimizing Patient-Centered Outcomes Research: Insights from a Patient Partner

Authentic research partnerships that truly value and integrate patient and caregiver perspectives help ensure that studies are patient-centered.

Communicating Complex Research Findings

Careful framing of results can help audiences interpret research findings appropriately.

Lessons in Transitional Care Service Delivery

The Value of Peer Mentors

Patients may not be readily accepted as peer mentors by clinicians, so it is important to help clinicians understand the value of this approach and work collaboratively with them in developing peer-mentor programs.

Engaging Multiple Stakeholders to Optimize Success

To optimize the success and sustainability of a new transitional care program, ensure that all key stakeholders are engaged as a vital part of the ongoing learning process. It is especially important to include insurers, senior health system executives, and patients.

Value of Home Visits

Home visits offer an unparalleled, valuable opportunity to understand patient needs and to increase patient engagement and self-efficacy in managing care transitions.

Turning Service Delivery Challenges into Opportunities to Improve Care

Emergency department (ED) visits can provide a valuable opportunity to identify patients who may benefit from robust transitional care support after discharge.