Arakelyan Stella, Anand Atul, Mercer Stewart W, Lone Nazir, Lyall Marcus J, Jacko Julie A, Guthrie Bruce
Advanced Care Research Centre, Usher Institute, University of Edinburgh, Edinburgh, UK.
BioQuarter - Gate, Usher Building, University of Edinburgh, 5-7, 3 Little France Rd, Edinburgh, EH16 4UX, UK.
BMC Geriatr. 2025 Aug 8;25(1):607. doi: 10.1186/s12877-025-06264-2.
The number of adults with multiple long-term conditions (MLTC) who experience frequent care transitions is rising. Improving care transitions for adults MLTC is important because transitions between and within care settings commonly lead to preventable adverse events. We explored multidisciplinary professional perspectives and experiences of managing care transitions for patients with MLTC to identify opportunities for improvement.
Qualitative interviews with 30 health and social care professionals in four Scottish integrated Health and Social Care Partnerships. Data were collected between May 2023 and March 2024. Thematic analysis was used, guided by the Sustainable Integrated Chronic Care Models for Multimorbidity: Delivery, Financing, and Performance (SELFIE) framework.
Care transitions were described as lacking person-centredness and consistency. Variability in decisions on cross-boundary acute care pathways was largely attributed to human factors (e.g., ease of arranging referrals, a lack of trust or awareness of Hospital at Home service) by hospital specialist staff, but to clinical complexity and home environment limitations (physical and social) by community staff. Ineffective interprofessional relationships and poor communication across services were common experiences, significantly driven by a lack of integration between IT systems affecting timely access to information and by services having different priorities and pressures. Workforce shortages, knowledge gaps in managing MLTC, and long-standing capacity issues in social care were identified as important barriers to effectively managing transitions.
We identified multiple system-level barriers to providing high-quality and safe care transitions. We proposed key improvement opportunities, highlighting the need for using system engineering and systems thinking approaches, underpinned by the active engagement of patients, carers, professionals, and wider stakeholders to drive meaningful and sustainable change in transitions of care.
患有多种长期病症（MLTC）且经历频繁护理转接的成年人数量正在增加。改善患有MLTC的成年人的护理转接很重要，因为护理环境之间以及护理环境内部的转接通常会导致可预防的不良事件。我们探讨了多学科专业人员对管理患有MLTC的患者护理转接的观点和经验，以确定改进机会。
对苏格兰四个综合健康与社会护理伙伴关系中的30名健康和社会护理专业人员进行了定性访谈。数据收集于2023年5月至2024年3月之间。采用主题分析法，以多病症可持续综合慢性病护理模式：提供、融资和绩效（SELFIE）框架为指导。
护理转接被描述为缺乏以患者为中心和一致性。跨边界急性护理途径决策的差异在很大程度上归因于医院专科工作人员的人为因素（例如，安排转诊的便利性、对居家医院服务缺乏信任或了解），但社区工作人员认为是临床复杂性和家庭环境限制（身体和社会方面）所致。跨专业关系无效和跨服务沟通不畅是常见情况，主要原因是影响及时获取信息的信息技术系统缺乏整合，以及各服务部门有不同的优先事项和压力。劳动力短缺、管理MLTC方面的知识差距以及社会护理中长期存在的能力问题被确定为有效管理转接的重要障碍。
我们确定了提供高质量和安全护理转接的多个系统层面障碍。我们提出了关键的改进机会，强调需要采用系统工程和系统思维方法，以患者、护理人员、专业人员和更广泛的利益相关者的积极参与为支撑，推动护理转接方面有意义和可持续的变革。
