Interview participant characteristics
Fourteen interviews were conducted with thirteen stakeholders as one stakeholder was interviewed twice on two actions. Among the five project coordinators that were interviewed, there were three pharmacists, one physiotherapist and one general practitioner. The eight other stakeholders involved in the transitional care actions were two general practitioners, one home care nurse, one cardiac nurse, one cardiologist, one physiotherapist and one policy advisor for welfare & care. Additional file 2 presents an overview of interview candidates across the four actions.
Transitional care actions
The thematic analysis and document analysis to describe four transitional care actions resulted in an item list that is presented for each of the four actions in Table 1. It includes the objective, transitional care focus, patient target group, main HCPs included, key components of the action, synergies, implementation status, context information. Additional file 3 lists all items and their meaning.
Experiences and perceptions
Thematic analysis to explore the stakeholders experiences on transitional care resulted into the five themes: 1. Involvement of HCPs in decision making, 2, Improved community feeling – reduced barriers of communication, 3. Supporting tools and learning opportunities for HCPs, 4. Transitional care for patients in practice, 5. Key challenges: coordination, resources, financial & political support. Each theme is described separately in the next sections.
Theme 1: involvement of HCP in decision making
HCPs appreciated being involved early on in shaping actions and welcomed the bottom-up approach from ZZL allowing them to propose own ideas for initiatives. Stakeholders felt motivated to be involved in all four actions that can benefit the care for their patients and bring themselves closer to local health care professionals from primary care and secondary care.
“The approach that we are not going to come to you with a finished programme, but you are going to have a say in that programme. They really like that, they feel acknowledged… “(project coordinator).
“And a lot of specific questions, a lot of input from primary care providers. That was greatly appreciated, because it was actually the first time that the primary care providers had the feeling that they could directly take part in this process.” (project coordinator).
Actions were considered as a potential leverage for change and positive experiences were shared with colleagues, who then convinced other HCPs to join. Moreover, HCPs appreciated that their input was taken into account while shaping actions and that for example a new role for coordinating pharmacists could be tested at the intermediate care center (Action 1). These positive changes triggered discussions on how health care professionals see their role and increased their confidence to be more assertive about being involved and voicing their opinion.
“The neighborhood teams also have a very strong pull effect and that is because they are set up by the care providers themselves.” (project coordinator).
“They’re stronger, more assertive, and they now also asked to join the vaccination centers. That also makes communication more easy. They have an opinion […] “(Project coordinator).
Theme 2: improved community feeling - reduced barriers for communication
Across all actions, stakeholders reported that the threshold for communication had reduced and they noticed a significant improvement in the overall team spirit. HCPs experienced more direct and straightforward communication with each other.
By doing so yes we have got to know each other, haven’t we? So now we know each other and yes we have a much lower threshold to send a Siilo message” (HCP 1).
Also, HCPs perceived an increased openness for providing interdisciplinary care. Stakeholders reported that the actions change their way of thinking about interdisciplinary care and that patients with chronic care needs should not be treated alone.
“There is much more openness to seeking and giving interdisciplinary advice “(HCP 1).
“And I think that this project has made me think more about the fact that chronic care, the people who need chronic care, should not be tackled alone. Um, that I should take steps towards other people and say, we’re going to tackle this more together.” (HCP 2).
In addition, the actions allowed HCP to get to know each other and to build up trust over time within and between primary care and secondary care. This was often highlighted in Action 1 where care decisions were shared with all involved HCPs using the Siilo application. A feeling of professional joy and being proud of what was achieved together was reported by one stakeholder.
“That professional joy that yes, everyone was really like that. I made my contribution here to a greater whole, even more than usual, you could really see that. Every little step that was taken by a particular care provider was shared in the group and everyone was like oh wow yes ok, we have to build on this. That was fantastic actually.” (HCP 3).
Theme 3: supporting tools and learning opportunities for HCPs
HCPs felt the necessity to have modern secure tools. The communication application Siilo was appreciated for small care teams allowing to solve misunderstandings, to make adjustments to the care plan or to receive information on medication in a quick and uncomplicated way.
“I am convinced that Siilo can work on a small scale in defined patient groups” (HCP 3).
Also, the paper envelope for conducting medication reconciliation was acknowledged by HCP as a tool for information transfer between hospital and the community pharmacy. Although many participants experienced these tools as useful, it was often stated that the current tools are seen as a temporary solution and a digital integrated patient record with messaging function is needed in the long-term.
“The problem lies in the fact that we still have to work on paper. Both for the home care nurses and for the pharmacists as well. So in Belgium there is no safe, for the time being, no platform where we can work together in the same module to follow up on the treatment [...] ”(Project coordinator).
HCP’s valued the learning opportunities that were provided within the actions. Stakeholders reported that the actions increased their awareness for the importance to conduct high-quality follow-up care (e.g. medication reconciliation guideline in action 3).
“I actually think that this is an added value because the envelope campaign made us aware that we can get some extra information from the patient that we sometimes don’t think of ourselves” (HCP 4).
Theme 4: transitional care for patients in practice
Across all actions, stakeholders perceived that the actions offered support to guide their patients through complex treatments. Stakeholders experienced that the transitional care actions led to increased consultations with patients allowing HCPs for a better understanding of patient needs which ultimately resulted in delivering a more focused care approach.
“But I think there is a lot more consultation and we can approach the care in a much more focused way and guide the people better” (HCP 5).
“Because you have a lot more, details about the person themselves. So I can really look more at what applies to this person. Not the generalized rattling off of questions to tell them. But with more information, you can indeed focus much more on the patient in front of you, in his individual context.” (HCP 4).
In addition, stakeholders shared feedback from primary care professionals highlighting improved knowledge and awareness of patients in better understanding early signs and symptoms of their disease. This was observed for patients who received a heart failure session during follow-up (Action 4), leading to improved awareness and increased independence.
“We have already heard from the home care nurses that the patients really do realize what they have to look out for. They are also becoming partly more independent, because they know that they have to start moving.” (HCP 5).
Moreover, stakeholders highlighted that the actions within the neighborhood allowed patients to connect with their community by joining activities organized at the local level (e.g. Action 2 – walking/exercising moments, group sessions).
“I think that at the moment, the impact of [name of neighborhood team]is certainly not that big on the things that you mention now. Erm, but it will rather have an impact on, erm, community work that brings people together more, such as the walks that are organized, the evenings that are organized around a particular theme” (HCP 6).
Although the actions offered additional support for their patients, stakeholders overall felt that actions provided limited follow-up after transition and provided limited possibilities for patient involvement. Action 3 and 4 provided a one-time moment for follow-up which was perceived as too short by participants to ensure continuity of care.
“But after that, it is up to the GP and the informal carer to follow up properly and there is no actual follow-up. There is no long-term follow-up within our project […]” (Project coordinator).
Also, many stakeholders perceived patient involvement as difficult in practice, partly due to technological challenges and partly due to their own reluctance in being involved in their own care. Difficulties were mentioned in particular for older vulnerable patients as they were asked to login to a patient platform which was perhaps not the right solution for this population group and did not provide flexible solutions. Additionally, stakeholders observed that patients did not agree to be included in the actions likely due to limited reach and awareness of ZZL or the COVID-19 situation that led to many cancellations.
“Um, but if we look at the chronic care population that I see, it’s mainly the 70-80 plus, yes. The whole internet thing, online login, all that stuff, is perhaps not so applicable to them. In 20 years’ time, it might be completely different, but at the moment it’s perhaps not perfectly adapted to the needs of the patient.” (HCP 2).
“It’s not always possible to really involve the patient according to the books, simply because sometimes there is a reluctance on the part of the patients and […]. I don’t mean to say that you can’t or you can’t do something about that, because that takes a lot of time, a lot of guidance” (HCP 7).
Theme 5: key challenges – communication, resources, financial & political support
A lack of concrete communication and coordination was reported, especially in the beginning of the pilot project as involved HCPs needed to take over new roles and responsibilities that often required to learn new skills. Therefore, bringing disciplines together and deciding on a common method for coordination was perceived as difficult.
“because I had the impression that everyone was a bit on their own, all the disciplines were a bit on their own, but not enough working together” (Project coordinator).
Additionally, stakeholders reported that a clear protocol for each action was missing, as a general project plan already existed that was used for all actions combined. This general project plan was set up in the development phase of the pilot project, however it was reported that the plan was modified in the meantime and not followed exactly as outlined. Stakeholders reported that the missing guidance created difficulties for implementation and decisions on ownership.
“But because it didn’t have a very clear protocol of ‘yes, we’re going to do it like this and like that’. In practice, it was a bit difficult to decide who should take the initiative for which patients” (HCP 2).
Moreover, the COVID-19 measurements impeded smooth communication and increased the effort needed to have regular meetings. For example, COVID-19 made it hard to onboard newly introduced roles such as coordinating pharmacists as all meetings were virtual and hence other HCPs were unaware of the existence of such roles.
“So yes, that was what was difficult because of COVID, that not everyone’s role was equally clear […]” (Project coordinator).
In addition to communication challenges, several structural challenges like increased workload of administrational tasks and shortness of staff was often mentioned. Also, due to the bottom-up approach from ZZL, HCPs active participation required extra energy and time, particularly in the early phase of the actions.
“But then you also have the problem of resources. Neighborhood teams, that’s not really backed up by structural resources. The future of Zorgzaam Leuven itself is not yet very clear.” (policy maker).
“I think for some colleagues it’s an extra burden at the moment because it’s still under construction, so it takes energy to think about how we’re going to change that and what does that mean for my own practice” (HCP 1).
Stakeholders also mentioned the lack of financial and political support. Financial resources were limited and there was limited regulatory leeway for projects to experiment with new care approaches. Moreover, stakeholders expressed that the lack of long-term perspective felt demotivating as no clear future and roadmap of ZZL was communicated making future planning of the various actions difficult.
“Especially I think from the government and from, yes from government agencies more support I think or more also more shorter possibilities to tune things and roll them out. In such a way that, yes, we can also give a perspective to the people we are working with. I have the feeling that we are not able to offer enough perspective […]” (Project coordinator).