Transitional care planning: A pilot study to explore patient, hospital, and primary care perspectives

The care plan aims to align key stakeholders via the exchange of meaningful, timely, and actionable patient care information during transitions of care. This exploratory study used a qualitative approach that includes field observations and semi-structured interviews to further understand the barriers and current process of care planning. A thematic analysis identified clinician strategies in addition to barriers at system, care-team, and patient levels. Specific themes included limited time and resources to establish value-based care, inconsistent/vague role definitions across settings, disconnections in care team communication, inconsistent care planning definitions and goals, patients’ lack of knowledge of care planning, and social behavioral determinants that prevent patients from engaging in their care planning. Further research is necessary to gain a deeper understanding of these barriers and clinician strategies to support a clearer definition of the care planning process.