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Home Health Care Services Quarterly, 34:185–203, 2015
Copyright © Taylor & Francis Group, LLC
ISSN: 0162-1424 print/1545-0856 online
DOI: 10.1080/01621424.2015.1092908
Identifying Challenges Associated With the
Care Transition Workflow From Hospital to
Skilled Home Health Care: Perspectives of
Home Health Care Agency Providers
MAHIYAR NASARWANJI, PhD
Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore,
Maryland, USA
NICOLE E. WERNER, PhD
Department of Industrial and Systems Engineering, University of Wisconsin–Madison,
Madison, Wisconsin, USA
KIMBERLY CARL, RN, BSN and DAWN HOHL, RN, PhD
Johns Hopkins Home Care Group, Baltimore, Maryland, USA
BRUCE LEFF, MD
Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins
University; Department of Community and Public Health, Johns Hopkins School of Nursing;
and Department of Health Policy and Management, Johns Hopkins Bloomberg School of
Public Health, Baltimore, Maryland, USA
AYSE P. GURSES, PhD
Armstrong Institute for Patient Safety and Quality, and the Department of Anesthesiology and
Critical Care, Johns Hopkins University; and Department of Health Policy and Management,
Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
ALICIA I. ARBAJE, MD, MPH
Armstrong Institute for Patient Safety and Quality, and the Division of Geriatric Medicine and
Gerontology, Department of Medicine, Johns Hopkins University; and Department of Clinical
Investigation, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
Older adults discharged from the hospital to skilled home health
care (SHHC) are at high risk for experiencing suboptimal tran-
sitions. Using the human factors approach of shadowing and
contextual inquiry, we studied the workflow for transitioning
Address correspondence to Alicia I. Arbaje, MD, MPH, Division of Geriatric Medicine
and Gerontology, Department of Medicine, Johns Hopkins University, 5200 Eastern Avenue,
Center Tower, 7th Floor, Baltimore, MD 21224, USA. E-mail: aarbaje@jhmi.edu
185
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186 M. Nasarwanji et al.
older adults from the hospital to SHHC. We created a represen-
tative diagram of the hospital to SHHC transition workflow, we
examined potential workflow variations, we categorized workflow
challenges, and we identified artifacts developed to manage varia-
tions and challenges. We identified three overarching challenges
to optimal care transitions—information access, coordination,
and communication/teamwork. Future investigations could test
whether redesigning the transition from hospital to SHHC, based
on our findings, improves workflow and care quality.
KEYWORDS care transitions, communication, frail elderly, home
health care, human factors engineering, qualitative research,
teamwork
Problems during care transitions of older adults are common, costly, and
sometimes lead to adverse events (Arbaje et al., 2014; Coleman & Boult,
2003; Coleman, Smith, Raha, & Min, 2005). After over two decades of
research focused on reducing such problems, unfavorable outcomes persist.
Readmissions rates remain high, and older adults are often dissatisfied with
the quality of their care (Coleman, Min, Chomiak, & Kramer, 2004; Jencks,
Williams, & Coleman, 2009; Sato, Shaffer, Arbaje, & Zuckerman, 2011). Older
adults who require skilled home health care (SHHC) services following hos-
pital discharge are among those at highest risk of experiencing suboptimal
outcomes during care transitions (Murtaugh & Litke, 2002; Rosati & Huang,
2007; Wolff, Meadow, Weiss, Boyd, & Leff, 2008). SHHC are services pro-
vided by health care professionals (e.g., nurses, physical therapists) in a
residential environment. Hospital readmission rates from the SHHC setting
are approximately 25%, with most occurring within 2–4 weeks after hospi-
tal discharge (Anderson, Hanson, DeVilder, & Helms, 1996; Ashton et al.,
1999). Although interventions exist to improve care transitions from hospital
to home (Arbaje et al., 2010; Boult et al., 2011; Coleman, Parry, Chalmers, &
Min, 2006; Jack et al., 2009; Naylor et al., 1999), given that re-hospitalization
rates from SHHC settings remain high (Madigan et al., 2012; Rosati & Huang,
2007), interventions that account for the complexity of the hospital to SHHC
transitions are still needed.
PURPOSE OF THE RESEARCH
Due to challenges associated with addressing the complex workflows expe-
rienced by SHHC providers, the need for a systems approach to improving
transitions has been identified (National Research Council Committee on the
Role of Human Factors in Home Health Care, 2011; Madigan & Anderson,
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Care Transition Workflow 187
1999). The use of a human factors and ergonomics (HFE) work systems
approach can facilitate the identification and mitigation of challenges related
to the complex transition workflow. HFE is a scientific discipline that studies
the interactions between humans and elements of their work system (e.g., a
hospital unit, an SHHC agency, an older adult’s home) to optimize overall
performance and reduce harm (Carayon, 2012; Carayon et al., 2014; Gurses,
Ozok, & Pronovost, 2011). The work system comprises of elements—such
as the people performing the work, the tasks they are performing, and the
tools they use to perform tasks within that context—that interact to perform
processes that produce outcomes (Carayon & Wood, 2010; Carayon et al.,
2006, 2014; Holden et al., 2013). Within the structure of a work system,
there are workflows, which are “the flow of people, equipment, information,
and tasks, in different places, and at different levels, at different time scales
... that are used or required to support the goals of the work domain”
(Carayon, 2012, p. 509). Challenges within the workflow are mechanisms
that impede the execution of the desired workflow. To better understand the
hospital to SHHC transition and its workflow challenges, we: (a) developed
a representative diagram of the coordinator transition workflow; (b) identi-
fied variations to the workflow; (c) categorized challenges to the workflow;
and (d) described the artifacts or aides created to manage variations and
challenges.
METHODS
Design
We used a HFE approach consisting of two methods: shadowing and con-
textual inquiry. Shadowing is a qualitative ethnographic method that makes
use of observation to collect detailed information about the tasks performed
within a workflow (McDonald, 2005). Contextual inquiry involves the col-
lection of detailed information about the tasks performed by asking probing
questions to clarify or gain an in-depth understanding of the tasks (Beyer &
Holtzblatt, 1997). We unobtrusively shadowed SHHC coordinators as they
performed all tasks in transitioning older adults from the hospital to an
SHHC. When shadowing, we asked probing questions as necessary to aug-
ment our observations. The Systems Engineering Initiative for Patient Safety
(SEIPS) guided our data collection during both shadowing and contextual
inquiry. SEIPS is an HFE work system model with five elements: (a) peo-
ple—e.g., nurses, older adults, caregivers, physicians, as well as teams of
providers and how they coordinate information and communicate with those
involved; (b) tasks that people perform; (c) tools and technology available
and needed to complete the tasks; (d) organizational factors shaping the
work, such as staffing and policies; and (e) factors related to the physi-
cal environment in which workflows are performed (Carayon et al., 2006;
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188 M. Nasarwanji et al.
Holden et al., 2013). These elements interact to constitute processes that
produce outcomes (Carayon et al., 2006; Holden et al., 2013). Based on
both the SEIPS model and our workflow conceptualization, two researchers
(MN, AA) developed a semi-structured guide for the contextual inquiry. The
guide included questions on the sequence of tasks; how, where, and by
whom tasks were performed; variations in the tasks, tools, and technolo-
gies used to perform tasks; and strategies used to overcome observed or
voiced challenges to task completion. We shadowed and performed contex-
tual inquiry in 4-hour intervals on different days and at different times, for a
total of 24 hours. During this time period, we observed hospital-based multi-
disciplinary rounds, older adult bedside visits, and office work involving
development and transmittal of referrals to the SHHC agency. We collected
data over 4 months in 2013.
Participants and Institutional Review Board Approval
We used purposive and network sampling (Crabtree & Miller, 1999) to iden-
tify health care professionals with substantial experience in transitioning
older adults from the hospital to the SHHC. Participants were from nine
medical and surgical units, and an SHHC agency affiliated with a large urban
academic hospital network. We did not place restrictions on the type of hos-
pital unit or cause of hospitalization when identifying the SHHC coordinators
to participate in the study. We enrolled 15 coordinators who fulfilled different
roles within the transition workflow, and who were responsible for initiating,
executing, and coordinating an older adult’s transition. Table 1 lists the spe-
cific roles and responsibilities of these coordinators and the other providers
identified to be involved in the the transition work system. This study was
approved by The Johns Hopkins School of Medicine’s Institutional Review
Board.
Data Collection and Analysis
We observed the transition from the time an older adult was identified as
needing an SHHC (occurring primarily in the hospital setting, 24–72 hours
prior or close to the time of discharge) to when the SHHC referral was com-
pleted and sent to an SHHC agency, but before the older adult was seen
for the initial SHHC start-of-care visit (occurring up to 72 hours after hos-
pital discharge). Although the transition continued beyond this parameter
with an initial home visit, the transition typically occurred in two parts: (a)
workflow prior to hospital discharge and (b) workflow after hospital dis-
charge. We focused on the workflow prior to hospital discharge, as it was
responsible for ensuring completeness and accuracy of information about
the transition, and identifying and securing the appropriate services.
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TABLE 1 Roles Involved in Initiating, Executing, and Coordinating the Transition of an Older Adult From the Hospital to an SHHC
Role Location Description of role (related to the hospital to SHHC transition)
SHHC coordinatoraHospitalbInitiates and executes the hospital to SHHC transition.
SHHC coordinator assistantaHospitalbProvides support to the SHHC coordinator, verifies insurance, finds
appropriate SHHC agency.
Physician Hospital Orders SHHC services, completes documentation certifying need for
SHHC, and determines older adult’s care plan.
Nurse practitioner/physician assistant Hospital Assists physician with documentation, and educates patient and
caregiver regarding care plan prior to discharge.
Hospital nurse Hospital Educates patient and caregiver regarding care plan prior to discharge.
Case manager Hospital Manages planning of care for multiple patients in a ward, oversees
multidisciplinary rounds, identifies need for postdischarge services,
and works with SHHC coordinator to identify patients in need of
SHHC.
Social worker; physical therapist;
occupational therapist; dietician
Hospital Identifies postdischarge needs and recommends appropriate services.
Insurance verification specialistaSHHC agency Ensures that SHHC agency can accept patient’s insurance and
reconciles discrepancies in insurance information.
Intake nurseaSHHC agency Ensures that SHHC agency has the required resources and can provide
the care recommended by the hospital.
ScheduleraSHHC agency Informs SHHC nurses of new cases, and manages schedules for all
SHHC nurses.
Older adult and informal caregiver Hospital, home Individual being transitioned; and able and willing individual who is
responsible for care for the older adult once at home.
aThese participants were shadowed and the focus of contextual inquiries for this study.
bThough these participants were located in the hospital, they were employed by the SHHC agency.
189
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190 M. Nasarwanji et al.
REPRESENTATIVE DIAGRAM OF COORDINATOR TRANSITION WORKFLOW
Using the notes and transcripts from our contextual inquiries, two HFE
experts (MN, AG) generated a list of chronological tasks. Each task was
annotated with the tools and technologies used to complete the task, and
the different people involved in the task. Tasks were then grouped into
independent “action groups” or sets of tasks that had to be completed dur-
ing the transition. Two HFE experts (MN, NW) and two geriatricians (AA, BL)
used the list to create a diagram depicting the workflow for a typical transi-
tion. SHHC subject matter experts, including SHHC administrators and SHHC
coordinators, reviewed the workflow diagram for accuracy and complete-
ness. To assess face and content validities, accuracy, and completeness of
the initial diagram, we presented it to SHHC nurse administrators during two
individual interview sessions, and made changes based on their feedback.
We then evaluated the diagram in two focus groups with SHHC coordina-
tors. We presented a final version of the diagram to two SHHC administrators
(DH, KC) and one SHHC coordinator for validation.
IDENTIFICATION OF VARIATIONS TO THE WORKFLOW
Due to the complexity of the work system, we anticipated that the workflow
diagram might not capture all of the nuances of the transition. Hence, to
provide a more comprehensive understanding of the transition, we identified
variations in the workflow by comparing the diagram to notes and transcripts
from the contextual inquiry. We defined a variation as any data representing
a change in the typical workflow as depicted in the diagram. Variations were
not necessarily negative and did not necessarily represent challenges, but
they were crucial to document and provided a comprehensive understanding
of how the transition is executed in real world situations.
CATEGORIZATION OF CHALLENGES TO SUCCESSFUL EXECUTION OF THE
WORKFLOW
During our shadowing and contextual inquiries, we also identified the
challenges coordinators encountered in completing the workflow. We cat-
egorized their challenges by the five elements of the SEIPS model. Then,
through group consensus, a group of HFE experts (AG, MN, NW), geriatri-
cians (AA, BL), and SHHC administrators (DH, KC) narrowed the challenges
into categories by similar content.
DESCRIPTION OF ARTIFACTS CREATED BY COORDINATORS
We documented artifacts or aides created by coordinators to manage the
variations and challenges encountered in the workflow. Artifacts are “those
artificial devices that maintain, display, or operate upon information to serve
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Care Transition Workflow 191
a representational function and that affect human cognitive performance”
(Carroll, 1991, p. 17). Artifacts often serve as memory aides, reference lists
or a means to communicate information.
RESULTS
Representative Diagram of Coordinator Transition Workflow
We identified 15 major tasks in the transition workflow diagram (Figure 1).
We categorized these tasks into five action groups: (a) identifying hospi-
talized older adults in need of SHHC services; (b) informing older adults
of SHHC options; (c) finding the appropriate SHHC agency; (d) gathering
and synthesize information to complete referral; and (e) informing SHHC of
referral.
IDENTIFY PATIENT IN NEED OF SHHC SERVICES
The two major mechanisms coordinators used to identify older adults in need
of SHHC services were to: (a) attend daily multidisciplinary rounds to gain
FIGURE 1 Hospital-to-SHHC transition workflow diagram prior to discharge, showing action
groups (column headers) and tasks (rows) that must be completed by specific roles (listed
under bullet points) using tools and technology (in parentheses) to reach the goal of that
action group.
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192 M. Nasarwanji et al.
information about older adults potentially in need of SHHC services; and
(b) maintain close contact with the hospital case manager responsible for
discharge planning. Once a potential referral was identified, the coordinator
assessed the older adult’s care needs and insurance eligibility.
INFORM PATIENT AND DISCUSS OPTIONS
The coordinator first established whether the older adult would accept SHHC
services. Once accepted, coordinators determined whether the older adult
had received SHHC services before or if a particular SHHC agency was pre-
ferred. The coordinator then determined if there was an able and willing
caregiver. Combined, these tasks required multiple phone calls, conversa-
tions with older adults and informal caregivers, and simultaneous tracking of
any changes in the older adult’s discharge status or care plan.
FIND AND CONFIRM AGENCY
The coordinator was also responsible for finding an appropriate SHHC
agency to staff the referral based on the needs and preferences of the older
adult, SHHC agency staffing abilities, and insurance eligibility. Coordinators
had to contact insurance companies and SHHC agencies to identify the
appropriate SHHC agency with the capability to provide for the older adult,
based on the discharge date.
GATHER AND SYNTHESIZE INFORMATION TO COMPLETE SHHC REFERRAL
As part of the transition process, the coordinator gathered and synthesized
the information needed to complete the referral, which included patient
history, demographic information, and the types of SHHC services needed.
It is important to note that this sequence of tasks was completed iteratively,
as care plans changed prior to discharge. For example, coordinators might
begin a referral for one SHHC service such as home oxygen, only to be
informed later that the older adult also needed physical therapy. Similarly,
the coordinator might not have had all of the information needed to complete
the referral. Thus, the coordinator sometimes needed to revise or amend a
referral prior to hospital discharge.
INFORM SHHC AGENCY OF REFERRAL
Upon completion of the SHHC referral, the coordinator sent the completed
referral to the SHHC agency. The SHHC agency verified insurance eligibility
and determined staffing needs prior to admitting the older adult to SHHC.
If the older adult was admitted to the SHHC agency, a health record was
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Care Transition Workflow 193
generated. This sequence of tasks was also iterative. Sometimes insurance
issues arose once the referral was sent to the agency, and the coordinator
was contacted to change the referral or find a new agency. For example,
coordinators may have initiated a referral with one SHHC agency based
on documented, but outdated, insurance information. A new insurer may
have been documented in one record system, but not in another. Often, this
change in information would require a change in SHHC agency. Another
example might be if the older adult’s discharge was delayed due to a change
in their clinical condition. In that case, the coordinator contacted the SHHC
agency and either sent an addendum or completed a new referral.
Each action group and related tasks required the coordinator to com-
municate or coordinate with other providers from the hospital care team
or the SHHC agency. Further, the coordinator used multiple tools and
technologies—both from the SHHC agency and the hospital—to arrange the
transition. Coordinators reported that the most common mode of communi-
cation was the telephone. In addition, coordinators used fax machines, email,
and pagers to communicate with other hospital providers and SHHC agen-
cies. Information was typically obtained from the hospital electronic medical
record or from in-person conversations with case managers or physicians.
Identification of Variations to the Workflow
As expected in the complex work system of the hospital, there were varia-
tions to and significant flexibility in the typical transition workflow presented
in Figure 1. Depending on each unique transition situation, tasks were added,
removed, or occurred in a different order. For example, coordinators typically
waited to receive physician orders before completing a referral. But when
physicians were not immediately available to verify orders and certify the
need for SHHC, coordinators would modify their workflow by partially com-
pleting the referrals and adding in physician orders at a later date. Sometimes,
the workflow was temporarily suspended, as in cases when the coordinator
visited the older adult to provide information, but found the room changed
or the older adult at therapy or a test. Changes in the older adult’s clinical
status often modified their SHHC needs in terms of treatment or the SHHC
start-of-care date. Often the referral needed to be redone, revised, or have
an addendum attached; and these changes then needed to be communicated
to the SHHC agency.
Categorization of Challenges to Successful Execution of the Workflow
Each action group within the workflow—both the typical workflow and the
variations—with its multiple tasks, coordinators, and tools, was susceptible to
challenges associated with its completion. Across the workflow, we identified
three main categories of challenges, as shown in Table 2.
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194 M. Nasarwanji et al.
TABLE 2 Challenges Identified as Part of the Hospital/SHHC Transition Workflow
Challenges Description
Information access
Information extraction Information needed by coordinators was located in multiple
record systems (electronic and paper) or needed to be
extracted from multiple fields in the EHR or lengthy notes.
Coordinators had difficulty identifying an older adult
needing SHHC due to vaguely defined conditions for
determining need.
Access to complete
information
Coordinators experienced referrals, discharge plans,
discharge summaries, medication lists, and related materials
with missing or incomplete information.
Coordination
Uncertainty in care
plans
Change(s) in the older adult’s condition typically warranted
amendments to the referral or a new discharge plan.
Management of
referrals
Coordinators had no systematic or specified method to track
and manage multiple SHHC referrals simultaneously.
Equipment
procurement
Coordinators experienced delayed delivery of durable
medical equipment or other supplies or incorrect items
delivered, and other difficulties in procuring or
coordinating equipment.
Communication/teamwork
Difficulty accessing
physicians
Coordinators had difficulty communicating with physicians
supervising the SHHC plan due to lack of access to a direct
phone line or pager, lack of timely response from the
physician, and difficulty securing required orders and other
documents such as face-to-face certifications, etc.
Communication
breakdown between
hospital providers
and SHHC
coordinators
An older adult’s situation may have changed and/or care
plans changed and documented by hospital providers, but
the information was not communicated to the coordinator.
Challenges with care
team members of
different roles
Coordinator had to consider other factors such as home
setting, family, social support, etc., when deciding on level
of care.
Lack of a clear
discharge plan
Coordinators received care plans outlined in the SHHC orders
and/or discharge instructions from hospital providers, but
the plans were not clear enough to execute and required
additional clarification.
INFORMATION ACCESS
Information access challenges identified within the workflow included chal-
lenges with information extraction, and receiving incomplete and/or missing
information. Information extraction was a challenge both when identifying
older adults who needed SHHC and when creating the referral. Coordinators
referred to themselves as “transition police,” intimating that they were con-
stantly trying to find information to ensure appropriate referrals. Garnering
information from multiple sources including electronic health records (EHR)
and charts was also a challenge. Coordinators explained that each physi-
cian put the information needed to complete SHHC referrals in different
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Care Transition Workflow 195
places. In addition, information in the EHR was often incomplete or incor-
rect, as the EHR had not been updated and specific details were often part
of lengthy physician notes. Thus, compiling all of the information to com-
plete a referral could take days and sometimes up to a week, leading to a
backlog of referrals. One coordinator described this scenario explaining, “I
have all my new referrals, but then I have a pile of [pending] referrals to
follow up on.” Information extraction also posed a challenge when the plan
of care or discharge status of an older adult changed. Coordinators were not
typically informed of changes and had to monitor multiple record systems
for any changes in the plan of care. Finally, coordinators often had access
to incomplete or outdated information to complete the referral, leading to
more information extraction challenges.
COORDINATION
Information and services had to be coordinated across health care set-
tings, but this coordination was constantly in flux, especially if there was
a change in the clinical state of the patient. This uncertainty in care plans
required SHHC coordinators to iteratively repeat tasks within the workflow.
In addition, there was no standardized or systematic way to manage multiple
referrals, and there were no tools to help support this task. Further, changes
to equipment procurement procedures made the coordination of equipment
one of the most frequently cited challenges. Equipment procurement chal-
lenges led to discharge delays, which then led to delays in admitting older
adults to SHHC.
COMMUNICATION AND TEAMWORK
Coordinators often cited a lack of a clear discharge plan, mainly due to
ineffective teamwork and communication as a factor leading to redundant
actions to complete a referral. Without enough information to execute the
transition, the coordinators had to find physicians to clarify information.
Coordinators regularly experienced difficulty accessing physicians due to
lack of access to a direct phone line or pager, or lack of timely response. For
example, coordinators often reported “hounding” physicians to ensure SHHC
orders were signed. One coordinator explained that, “sometimes you are
chasing down five doctors to get the information you need for one referral.”
They also experienced communication breakdowns between other hospi-
tal providers and coordinators. Coordinators felt like “detectives,” because
instead of having information communicated to them, they felt they had to
find information on their own. Coordinators were frustrated with the feeling
that they were “the last in the loop” and felt that one of their greatest chal-
lenges was waiting for information from the hospital provider team (i.e.,
physicians, hospital nurses, case managers). Attempting to identify older
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196 M. Nasarwanji et al.
adults for SHHC sometimes lead to challenges with care team members in
different roles due to contradictory opinions about the older adult’s needs
and SHHC eligibility criteria. Coordinators attributed these differences to the
hospital care team not fully understanding SHHC eligibility and services, and
to the need to have clarification about each provider’s role in the transi-
tion. This challenge often led to increased time and effort when referring a
patient who might not be appropriate for the SHHC, and took away time
from referring patients who were more appropriate for SHHC.
Description of Artifacts Created by Coordinators
The artifacts we identified were most often created by coordinators to man-
age both variations in and challenges to the workflow. Table 3 provides a
summary of the artifacts identified and their purpose in facilitating transitions.
TABLE 3 Description of Artifacts Created to Support Transition Workflow
Artifact Description and purpose
Transition workflow
challenge overcome by
creating artifact
Sticky note hand-offs Coordinators created their own
strategies for informing the next
coordinator on duty about
potential and pending SHHC
referrals.
Information access,
coordination
File of extra forms Coordinators carried a file of extra
forms such as the SHHC orders
document to increase chances of
obtaining documentation from
physicians.
Communication/teamwork
Personal reference
guides
Each coordinator created their own
reference guide of insurance
contacts, SHHC agency
information, and physician pager
and personal cell phone
numbers.
Information extraction,
coordination
SHHC “Bible” One group of coordinators created
a reference guide of
difficult-to-find contact
information for use in the office.
Information extraction,
coordination
Printed list of potential
patients
Coordinators printed a list of
current patients and used this list
to track pending and potential
patients by notating and highlight
the list.
Information extraction,
coordination,
communication/teamwork
Layout of work
environment
Coordinators organized their
workspace by stacking SHHC
referrals spatially to represent
pending, past, and potential
referrals.
Information access
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Care Transition Workflow 197
Paper artifacts (records, notes, instructions,andannotations made) played
a major role in completing the SHHC referral. Coordinators printed lists of
older adults who would be discussed during multidisciplinary rounds, and
took notes on the lists about next actions, follow-up, and questions they had
for any potential SHHC referrals. They used these documents to track older
adults as they moved toward discharge and to assist in completing the SHHC
referral. Artifacts were also created to communicate between coordinators
and other providers. For example, coordinators referred to sticky notes and
printed e-mails as “hand-offs,” and attached them to the SHHC “bible”—a
compiled book of all insurance and SHHC agency information—when they
needed to pass information to another coordinator. Others reported creating
their own reference guides for hard-to-find information or relied on more
senior members of the team for help with challenging tasks. One coordina-
tor explained, “We all have our own manuals that we have created to help
us [perform transitions].” To overcome difficulties accessing physicians and
obtaining necessary documentation, the coordinators traveled with printed
copies of their commonly used forms, such as SHHC orders and face-to-face
forms, to have physicians complete if the opportunity arose. Coordinators
also developed their own systems to manage multiple and partially com-
pleted referrals. Some used their desk space to spatially organize referrals
into stacks of completed, in progress, incomplete, revised, and potential
referrals.
DISCUSSION
Currently, transition interventions focus on the older adult transitioning from
the hospital to home (Coleman et al., 2006; Jack et al., 2009; Naylor et al.,
1999). These interventions are primarily at the patient level (Boling, 2006,
2009; Kripalani et al., 2007) and do not specifically account for challenges
associated with clinical workflow during complex transitions. To help bridge
this gap, some have called for a systems approach to improving transitions
(Arbaje et al., 2014; Madigan & Anderson, 1999). In our study, we used an
innovative HFE work systems approach and gained a rich, detailed under-
standing of the work performed by coordinators who are responsible for
initiating, executing, and coordinating the transition of older adults from the
hospital to SHHC. We identified complex nonstandardized transition work-
flows, as coordinators developed their own strategies to manage limitations
in the current work system. By analyzing the workflow, variations in the
workflow, and artifacts used by the coordinators, we identified novel chal-
lenges that begin prior to hospital discharge and continued throughout the
transition. Our findings have important implications for re-engineering the
work system to guide the improvement of transitions.
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198 M. Nasarwanji et al.
Having access to information that was accurate, up to date, and con-
cisely presented was critical to coordinators during the transition. Adequate
information sharing between the coordinators, and seamless information
flow to and from other providers were equally important. Artifacts created by
coordinators helped cope with limitations in the workflow, since tools and
technologies were inadequate to support the information needs of coordina-
tors. Some of the information management challenges could be remediated
by health information technologies (HIT). These HIT solutions would need to
focus on improving information access, electronic information sharing, seam-
less information transmission, compatibility between electronic information
systems, and a streamlined user interface design.
Recent research has shown that designing interventions based on an
HFE workflow analysis has improved performance in health care (Arthur
et al., 2012; Fernandez-Gutierrez et al., 2015; Möckel, Searle, Hüttner, &
Vollert, 2015; Tacker, Topardo, Mahaffey, & Perrotta, 2014). Transition inter-
ventions and HIT systems in hospitals are often designed and implemented
without accounting for the needs of the clinicians or having undergone an
adequate analysis of workflows, both of which lead to unintended con-
sequences. There is a need to design the next generation of transition
interventions and HIT solutions to support coordinator workflow, and to
assist in the execution of multiple and simultaneous transitions. Adopting
a human system integration, or user-centered design approach, may help
overcome some of the challenges identified with the current systems.
A lack of situation awareness within the transition workflow leads to
a myriad of coordination challenges, especially when care plans are in flux.
Situation awareness is an HFE construct that refers to the level of comprehen-
sion and coherent representation of the current system state (Endsley, 1995a,
1995b). Tools to increase situation awareness could take the form of shared
office space, interoperable data documentation systems, and automatic notifi-
cations of changes to the clinical status or care plan. Implementing solutions
such as HIT platforms that support shared situation awareness across the
provider team would support coordinator workflow by improving real-time
knowledge of changes to care plans and SHHC needs that impact the older
adult’s transition. Coordinators wanted open lines of communication with
other hospital providers to foster information sharing. Other health care
teams have improved this by bringing providers together using specific com-
munication tools to openly discuss the needs of each group, thus improving
the shared mental model—i.e., a shared understanding among team mem-
bers of the role of other team members and what each needs to do their
work. These open discussions can improve team cohesiveness by bring-
ing awareness to common goals. In addition, communication challenges
had an overall negative impact on the functioning of teams. Our findings
suggest a culture change is needed, as well as clarifying roles and increas-
ing accountability of members of the transition team. This culture change
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Care Transition Workflow 199
could address some of the communication/teamwork challenges we found.
Others have shown that both ambiguity in accountability and incongruence
between ideal and routine roles are important factors leading to subopti-
mal care transitions (Schoenborn, Arbaje, Eubank, Maynor, & Carrese, 2013).
Historically, the culture of health care in general has used the medical model
as a framework for service delivery, which has notable limitations for improv-
ing transitional care (Rooney & Arbaje, 2012–2013). The medical model for
diagnosing and treating illness focuses on treating dysfunction caused by
biological aspects of specific diseases and conditions. The main limitation of
using this approach alone to guide service delivery is the absence of recog-
nition of other factors affecting health care utilization—such as the patient,
caregiver, health care provider, work system, community, and regional
factors.
There are important implications of our work in the context of the
Affordable Care Act (ACA), which encourages the creation of accountable-
care organizations (ACOs) and partnerships with community-based organi-
zations to execute smooth transitions and deliver quality care after hospital
discharge. The Department of Health and Human Services announced that
by 2018, 90% of fee-for-service Medicare payments would be tied to qual-
ity or value of care (Burwell, 2015; Gurwitz et al., 2003). The alternative
payment models needed to support ACOs will further incentivize health
care organizations to develop seamless coordination during transitions, since
organizations will now be financially at risk if patients experience problems
during the transition or after discharge. The findings of our work can help
guide health care organizations in their efforts to design more seamless care
transitions for older adults.
Limitations
Three limitations of this study should be considered. First, it was conducted
with coordinators affiliated with one SHHC agency and might not represent
the experiences of coordinators and SHHC providers elsewhere; although,
the themes identified would likely resonate with similar stakeholders in other
settings. Second, the study did not include the perspectives of other partic-
ipants in the transitions—such as older adults, family caregivers, hospital
nurses, or rehabilitation therapists. Although these perspectives are impor-
tant, we chose to examine the views of health care professionals responsible
for initiating and executing older adults’ transitions and those who were
likely to be directly affected by workflow challenges, as these views were
not sufficiently represented in the literature and can complement the views
of other stakeholders. Third, the study focuses on transition quality itself and
not on clinical outcomes or health care utilization that might result from the
quality of the transition—e.g., re-hospitalizations.
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200 M. Nasarwanji et al.
CONCLUSIONS
The purpose of this research was to understand hospital-to-SHHC transi-
tion workflow, identify common variations in the workflow, identify artifacts
used during care transitions, and categorize challenges associated with the
transition workflow. Our findings suggest the need for improved informa-
tion access, coordination, and communication/teamwork solutions during
an older adult’s transition from the hospital to SHHC. Coordinators need the
ability to create a referral using information from the entire health care team
and a way to seamlessly transition information across health care settings.
Applying an HFE work systems approach to evaluate transition challenges
provided insights that aid our understanding of transitions and have impor-
tant implications for improving transitions. Our findings have implications
for ways to engineer the work system to improve transitions. Improved HIT
and culture change are two recommendations to help combat some of the
challenges with the current transition workflow. Future investigations could
test whether work system redesign could improve coordinators’ workflow
and quality of care provided during transitions.
ACKNOWLEDGMENTS
We acknowledge Deborah Statom for her support in organizing the rele-
vant literature and the Johns Hopkins Home Care Group and their staff
for their continued support of this research. An abstract of this work was
presented as a poster at the Academy Health annual research conference in
2013, Baltimore, MD. We thank Ryan Fongemie, Medical Illustrator, Center for
Teaching and Learning, Johns Hopkins Bloomberg School of Public Health,
for her assistance with preparing Figure 1.
FUNDING
Mr. Nasarwanji was supported by funding from the National Patient Safety
Foundation. Dr. Arbaje is a former Robert Wood Johnson Foundation
Harold Amos Medical Faculty Development Program Scholar, supported by
Grant Number 63518; a former National Patient Safety Foundation Research
Scholar; and a former Johns Hopkins Clinical Research Scholar, supported
by Grant Number KL2TR001077. Dr. Arbaje has received funding from the
Secunda Family Foundation, the John A. Hartford Foundation, and the Johns
Hopkins University School of Nursing Center for Innovative Care in Aging.
She currently receives funding from the Agency for Healthcare Research
and Quality (Grant Number 1K08HS022916). The funders had no role in
any of the following activities: design and conduct of the study; collection,
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Care Transition Workflow 201
management, analysis, and interpretation of the data; and preparation,
review, or approval of the manuscript.
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