Members of the Transitional Care Evidence to Action Network share lessons learned about conducting patient-centered transitional care research in real-world settings.
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:
Lessons in Transitional Care Research
Think about how to monitor intervention fidelity early in the planning of pragmatic trials and expect to adapt the process along the way.
Exploring the concept of engagement in creative ways helps researchers and community partners define a shared vision for engagement in research.
To develop and refine a patient-centered intervention, assemble an autonomous group of patients and stakeholders and ask yourself whose voice is still missing.
For a comprehensive assessment of a transitional care intervention, purposefully plan for and systematically document the resources required to implement the program.
To help make research findings actionable, begin planning early and engage patient partners and other stakeholders in the process.
Authentic research partnerships that truly value and integrate patient and caregiver perspectives help ensure that studies are patient-centered.
Lessons in Transitional Care Service Delivery
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.
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.
Home visits offer an unparalleled, valuable opportunity to understand patient needs and to increase patient engagement and self-efficacy in managing care transitions.
Emergency department (ED) visits can provide a valuable opportunity to identify patients who may benefit from robust transitional care support after discharge.