Background

Innovations in transitional care (TC) are often implemented to ensure an optimal continuity of healthcare delivery for older persons who transfer between multiple care settings. Older persons aged 65 years and above are at high risk of adverse events during care transitions due to the prevalence of chronic diseases and multimorbidity [1,2,3,4,5,6,7]. Care transitions of older persons are frequently hampered by a diversity of issues, such as, but not limited to, fragmented care, medication errors, or poor communication among healthcare providers [7, 8]. Consequently, the delivery of proper TC for the older population is not always achieved.

There appears to be an urgent need to innovate in order to alleviate the augmented demand for long-term care (LTC) services and promote better and safer care transitions. Based on the World Health Organization’s concept of LTC, we adapted its definition to fit the use throughout this article as “LTC refers to the provision of continuous care activities performed by formal and/or informal/family caregivers to ensure that older persons with or at risk of a significant ongoing loss of intrinsic capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms, and human dignity; also it can be achieved through: (a) optimizing the older person’s trajectory of intrinsic capacity, (b) compensating for a loss of capacity by providing the environmental support and care necessary to maintain functional ability at a level that ensures well-being; and can be provided in settings, such as but not limited to: nursing and residential care facilities, assisted living facilities, or private/own home” [9]. To that end, multiple evidence-based TC interventions, models, or programs also referred to as “innovations” have been developed with the goal to improve or prevent transitions between different settings [2]. According to existing literature, we defined the following terms to be used throughout this article: “improve care transitions”—to provide and enhance the transitional care and services delivered during physical relocations of older persons from one care setting to another, with a view to creating optimal benefit as a result of the care transition; “prevent care transitions”—to provide the care and services needed in order to avert an unnecessary or avoidable physical movement of older persons between two care settings or more [2, 5, 7]. The Transitional Care Model and Coleman’s Care Transitions Intervention are examples of interventions designed to improve care transitions from hospital to home [2]. Key components of these interventions include appointing a transition coach or nurse, encouraging patient self-management, and planning hospital discharge [10,11,12]. While other interventions [13] aim to prevent care transitions from nursing home to hospital through the use of specific advanced care planning tools, alternative interventions focus on providing acute care at home to prevent transitions from home to hospital [14]. The successful implementation of these interventions has been shown to enhance the quality of care, control costs, reduce hospital readmission rates, and ultimately meet patient needs [2, 15]. However, while innovation in TC is encouraged as a solution, its implementation is often difficult and unsuccessful.

The success or failure of the implementation of any innovation within a healthcare setting is usually influenced by multiple factors recognized as either barriers or facilitators [16]. These factors can be linked to either the innovation characteristics, individual professionals, patients and caregivers, organizational structure, or the environmental context [16, 17]. Nevertheless, other factors related to the actual process and activities undertaken to implement an innovation such as the planning, execution, and evaluation methods are as crucial [17]. Similarly, attempts to implement innovations in TC are frequently affected by multiple factors. Among the barriers are limited organizational resources, absence of an implementation climate, complexity of the innovations, and low leadership engagement [18, 19]. Conversely, facilitators include the adaptability of innovations, a high relative advantage of the innovation as perceived by users, and the existence of robust external organizational partnerships [14, 19].

However, to the best of our knowledge, no overview exists on barriers and facilitators that influence the implementation of innovations for preventing or improving care transitions for older persons. Thus, there is a need to explore and map the available evidence on these implementation factors. The main research question of the current study is the following: What are the barriers and facilitators that influence the implementation of TC innovations for older persons in long-term care settings? A secondary question is whether the literature captured the perspectives of older persons and informal or family caregivers on the innovation’s implementation and overall experience, and if so, what was reported as feedback.

Methods

This sco** review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Sco** Reviews (PRISMA-ScR) checklist [20] (see Additional file 1). The review was conducted according to the five stages described by the Arksey and O’Malley framework [21] and the enhancements proposed by Levac et al. [22].

Stage 1: identifying the research question

This sco** review is guided by the following question: What are the barriers and facilitators that influence the implementation of TC innovations for older persons in long-term care settings?

Stage 2: identifying relevant studies

Initially on July 25, 2019, a systematic search of three databases was conducted: PubMed/MEDLINE, EMBASE, and CINAHL; an update was run on March 10, 2020. Four main concept terms were used in the search: implementation; care transition; innovation; and older persons. To formulate the search strings, relevant keywords and synonyms were identified for each concept term in addition to the controlled vocabulary terms (such as MeSH headings in PubMed/MEDLINE). The search strategy was discussed by the authors as well as reviewed by an information specialist. Reference lists of articles that fulfilled the inclusion criteria were searched to identify additional papers. The final search strategy is available (see Additional file 2).

Stage 3: study selection

Literature published in any language between January 1, 2000, and March 10, 2020, was retrieved.

Original research studies were included. Articles were eligible for inclusion if (a) target population (participants or receiver of care) were all or if the majority were older persons aged 65 years and above (also referred to as patients, older adults, frail older adults, elderly) with long-term care needs and at risk of care transitions; (b) focused on the transfer and physical movement of older persons between two or more care settings with at least one setting providing long-term care; (c) implemented an innovation within a care setting to prevent or improve care transitions; (d) reported on the barriers and facilitators that influenced the implementation process of the innovation; (e) stated the perspectives of the older persons, family, informal caregivers, and/or healthcare providers on the innovation.

After the removal of duplicates, the first author (AF) screened the titles and abstracts for eligibility. In order to increase reliability, the second author (LG) screened a random selection of 10% of the total records for titles and abstracts [23]. Both reviewers then compared their assessment decisions and resolved any differences through discussion and when necessary through consultation with the author (BdB). In the next phase, the two authors (AF, LG) independently screened and discussed 100% of the full texts of those articles deemed eligible [23, 24]. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flowchart [25] was used to report the study selection process.

Stage 4: charting the data

Development of the data charting forms

A data charting form consisting of two parts was developed. Data charting form—part 1 comprised the following: title; authors; year; country; study aim; design and methodology; population; setting; innovation description; duration and phase of implementation; presence of barriers and/or facilitators to innovation implementation; reported themes of barriers and/or facilitators to the implementation of the innovation; perspectives of older persons, family, or informal caregivers and/or providers on the innovation; and reported implications of the innovation. Data charting form—part 2 was devised to map barriers and facilitators as identified in the studies to the Consolidated Framework for Implementation Research (CFIR) [26] and the Care Transitions Framework (CTF) [27].

The CFIR is composed of five domains: (i) intervention characteristics; (ii) outer setting; (iii) inner setting; (iv) characteristics of individuals; (v) process, and 39 standardized constructs and subconstructs [26]. This framework helps researchers identify the factors (i.e., barriers and facilitators) that influence the implementation of innovations [28]. Moreover, specific constructs from the CTF [27] were selected and used in supplement to the CFIR (see Additional file 3). The CTF is an adaptation of the CFIR, whereby it incorporates all the CFIR constructs in addition to new ones, which are mostly relevant to transitional care.

Testing of data charting forms and the charting process

Both forms were tested initially on two articles, and then results were discussed critically within the research team. It was agreed to include additional elements to describe further the innovations’ features in data charting form 1. In the data charting, the implementation factors and themes were extracted from the included articles and then mapped to the CFIR’s relevant domains, constructs, and the selected CTF constructs using the CFIR codebook [29]. Subsequently, the CFIR rating rules were used to determine each factor’s influence as negative: a barrier, or positive: a facilitator [30]. Two authors (AF, TvA) charted data independently from five randomly selected articles. Disagreements on map** factors to CFIR/CTF constructs were resolved between the two authors leading to a consensus. Afterwards, author AF completed the full data charting for all the included articles.

Stage 5: collating, summarizing, and reporting the results

The data charted were synthesized as follows:

  1. a.

    Description of included studies: classification of the studies into four groups according to the care transition pathways of each TC innovation; included the author(s), year of publication, country, objective, population, design, and methods.

  2. b.

    Description of the TC innovations: classification of the innovations into four groups according to the specific care transition pathways; included the target population, key components, and the CFIR domains influencing their implementation.

  3. c.

    Barriers and facilitators to implementation of TC innovations: the frequency of the reported factors identified as barriers and/or facilitators to the implementation was calculated based on their presence in the number of studies.

  4. d.

    Perspectives of older persons, family, or informal caregivers: a narrative description of the feedback on the overall experience, satisfaction with, or views on the implementation of the TC innovation.

Results

Study selection

Initially, 1537 studies were identified, and 21 were included in the final stage. The flowchart for the selection process is depicted in Fig. 1.

Fig. 1
figure 1

PRISMA flowchart of study selection process

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Study characteristics

The 21 studies included described the implementation of 20 different TC innovations (see Table 1). Almost half of the studies (N = 11, 52%) originated from the USA, and five were from Europe. The majority of the studies were process evaluations and were performed during or post the implementation of a TC innovation to examine the influencing factors. Most studies used qualitative research methods, and 11 utilized a preselected evaluation, implementation, or quality-related framework, tool, model, or instrument to guide data collection such as interviews and/or data analysis.

Table 1 Characteristics of the 21 included studies
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Study populations across all studies were comprised of multiple healthcare professionals and providers. Only six studies included older persons or family/informal caregivers and explored their perspectives on the TC innovations [36, 37, 41, 44, 46, 47].

Key features of the TC innovations

Sixteen innovations focused on improving care transitions for older persons, while four focused on preventing transitions. TC innovations were classified into groups according to the care transition pathways (see Table 2).

Table 2 Description and key features of the 20 TC innovations
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Description of the four groups of TC innovations

Care transitions from hospital to home settings were the focus of ten TC innovations. Improving care transitions was the main aim of these innovations with common goals to reduce hospital readmissions, lower healthcare costs [31, 34,35,36, 39, 42, 43]. All four innovations were designed for older persons who concluded an episode of acute care at hospital but were unfit to transfer to home or another final long-term care destination. The creation of “transition intermediary care places” such as transfer beds hosted within a residential care facility or community setting was the notable component across these innovations [41,42,43,44]. Hence, the four TC innovations allowed extra time to organize a more personalized arrangement for the long-term care final destination for older persons.

Care transitions from hospital or home to nursing/residential care facility were the focus of two TC innovations. The goal of these innovations was to improve care transitions with the objective to enhance information transfer between hospitals and nursing facilities and promote continuity of care. The essential aspect of both innovations was the provision of “transition advice & support” to nursing facility staff. This was enabled through the arrangement of community geriatric services and a psychiatric community nurse [45, 46].

Care transitions from nursing facility or home to hospital were the focus of four TC innovations. These innovations aimed to prevent care transitions. Hence, the main objectives were the provision of a value-based and patient-centered high-quality care [14], as well as the reduction and prevention of avoidable hospitalizations [47, 48], and reducing the frequency of transfers to acute hospital care [49]. The unique component of all four innovations was “transition care management in place.”

Barriers and facilitators to the implementation of TC innovations

Factors reported in the 21 studies could be mapped to 61 CFIR&CTF constructs, out of which 19 were reported as barriers only, 8 as facilitators only, and 34 as both barriers and facilitators. Among these 34 factors, 15 were reported as having both influences concurrently in the same study. The reporting frequency, presented as number of studies, for the barriers and facilitators influencing the implementation of the transitional care innovations as mapped to the CFIR&CTF constructs is shown in Fig. 2.

Fig. 2
figure 2

Frequency of reported barriers and facilitators to TC innovations implementation, mapped to CFIR&CTF (61 constructs). The asterisk(*) represents factors cited by at least 5 studies (25%) as a barrier and/or facilitator; the caret(^) denotes factor as a predominant barrier or facilitator; total number of studies is 21

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The most commonly reported domains impacting implementation were process (20 studies) and inner setting (19 studies), while factors in the outer setting were least reported (12 studies). Twenty-five factors were reported by at least five studies (25%) and therefore were considered the most prominent ones. Among these factors, we distinguished seven factors as predominant barriers and seven as predominant facilitators. The remaining 11 factors showed a nearly equivalent direction of influence as impeding and facilitating (i.e., indistinguishable). Here we use “predominant” when a factor was clearly and more frequently reported as either a barrier or facilitator, judged by whether at least two thirds of the total number of studies reporting this factor reported it as a barrier or facilitator. Nevertheless, this does not directly imply that these factors are the most important, but it conveys that they are very likely to affect the implementation of TC innovations in either direction of influence. The main findings describing the most prominent factors are presented below, and Fig. 3 provides an overall summary.

Fig. 3
figure 3

Overview of the factors influencing the implementation of TC innovations

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Factors—predominantly barriers

Targeted groups

A mismatch between the TC innovation components and the intended profile of the recipients, older persons, was evident to affect its implementation as indicated in nine studies [14, 18, 31, 32, 34,35,36, 43, 47]. Five studies reported that unclear eligibility criteria of the TC innovation often impeded the identification of older persons that could benefit from it [14, 18, 32, 35, 47]. Another four studies stated that TC innovations were unable to meet the specific care needs of the targeted older persons due to the high frailty and complex conditions of the recipients, confirming an incompatible fit [31, 34, 36, 43].

Complexity

The intricacy of the TC innovation design and the difficulty of putting it into action were reported mutually in five studies [14, 31, 36, 38, 39]. Two studies cited that the necessity to involve multiple homecare service providers [14] and informal caregivers [31], and the absence of bundled care payment methods [14] led to difficulty in implementing TC innovations in home settings. Healthcare providers perceived that TC innovations with complex and extensive processes [39], unstandardized or detailed protocols [36], and hard to understand and use tools and checklists [38] affected the implementation negatively.

Readiness for implementation: available resources

Low staffing levels [43, 44, 46] and a lack of dedicated staff [14] were common impeding factors to the implementation of TC innovations. Similarly, staff turnover [38, 47, 49] plus losing key team members [39] and major program staff and contact persons [56, 57]. Moreover and in our attempt to answer the second research question, this review found only few studies that took the perspectives of transitional care recipients into account, while examining the implementation of TC innovations. The role of the older persons and thereby the consideration of their wishes and needs in the implementation process appear to be limited. Hence, the older persons and/or their informal or family caregivers’ reflection on the actual implementation challenges are understudied, since the providers’ perspectives are often those sought after.

Furthermore, the specific context and characteristics of LTC organizations play an integral role in implementing innovations [58,59,60,61,62]. Correspondingly, our results indicated that the LTC organizational culture, implementation climate, readiness for implementation, implementation process, the individuals’ skills and attributes, and internal communication dynamics have a major impact on the uptake of several TC innovations. This provides further evidence regarding the theory on organizational readiness for change (ORC) by Weiner [63], which explains that fostering the organization’s capacity, commitment, and efficacy to change are notable drivers in creating readiness and ultimately enhance implementation. Similarly, our results affirm the work of Attieh et al. [64], in which five core theoretical components of ORC were identified including the organizational dynamics, change process, innovation readiness, institutional readiness, and personal readiness. Our results indicate that lacking resources often hindered the implementation of various TC innovations, and that the organizational culture had a prominent yet mixed influence on bringing about a change. According to Weiner [63], organizational resources and culture are among the contextual factors that can affect the organizational capacity and readiness for change. This review also identified that the individuals’ skills, knowledge, perceived attitudes, and designated roles were prominent factors in implementing an innovation. This is evident as per Holt’s et al. [65] and Weiner’s [63] concepts of change efficacy, which explain that individuals in an organization with a high shared collective capability and confidence to implement new tasks successfully can enhance the organizational readiness for change. In addition, our findings on the importance of implementation climate explained by the individuals’ relative priority to implement a TC innovation within an organization as well as their motivation levels relate to the organizational change commitment [63, 65, 66]. Lastly, the literature indicated that organizational leadership and internal communication dynamics are instrumental in generating readiness for change, as was mirrored in our results [63, 66].

Future recommendations

Research

Prospective studies on the degree of influence of each identified barrier and facilitator on the implementation of a TC innovation are needed. This will enable the development of tailored implementation strategies by addressing the prioritized factors. Furthermore, focusing on the older person’s perspective when studying the implementation process of TC innovations is required. This will alleviate the discontinuous and problematic care transitions for the older population.

Policy and practice in transitional care

Future implementation of TC innovations can benefit from a preassessment of the key components that underpin an LTC organization’s readiness for change by using established ORC measurement instruments [67]. Overall, these measures can offer an initial support for LTC organizations to better prepare for implementing innovations by reducing blinded change efforts. Simultaneously, LTC organizations can leverage their readiness for implementing change by, for example, adopting the concept of innovation management as reflected in A.T. Kearney’s House of Innovation [68]. This framework invites organizations to start with an innovation strategy and build an innovative and open culture. In addition, organizations must manage the innovation’s process in an integrated and continuous manner from idea conception to implementation, as a way to avoid inefficiencies and ensure timely positive outcomes. Bates et al. [58] emphasized the power to create successful innovative healthcare environments by making innovation a strategic priority. Henceforth, we recommend LTC organizations bolster their innovation readiness and management, whereby they encourage among professionals an incessant mindset of “change is the norm.” Nevertheless, this readiness should be fostered across the continuum of care spanning multiple LTC settings, given the nature of TC. In addition, transition roles or implementation support practitioners [69] should be instituted to better operationalize innovations in TC.

Strengths and limitations

We consider the combined use of CFIR and CTF a methodological asset for conducting this review, especially in the process of data extraction and map** of factors. The CFIR provided an intricate yet systematic way to understand the interconnectedness of the numerous factors. The inclusion of constructs from the CTF was found vital in detecting factors specific to care transitions. On the other hand, we acknowledge that different or additional factors could have been found had we chosen to use another framework.

This review has some limitations. First, it is subject to publication bias, since we only included articles published in peer-reviewed journals and excluded gray literature, preregistries, and policy documents. Second, even though we used an extensive search strategy to identify relevant studies on implementing TC innovations, we might have missed some potentially relevant papers, as the aim of innovations in LTC is not always clearly described. Third, not all records were screened by two persons; only a random selection of 10% of the initial total records was screened by a second reviewer for titles and abstracts. Though agreement seemed satisfactory, we cannot fully rule out that some relevant sources could have been missed. Fourth, we did not perform critical appraisal for the included studies, even though it is not mandatory in sco** reviews’ methodology, it could have added to the interpretability of the findings.

Conclusions

A diversity of factors impact the implementation of TC innovations; these include the innovation’s complexity, relative advantage and evidence strength, organizational readiness for implementation, individuals’ knowledge and beliefs, and the implementation process planning and evaluation. To ensure implementation potential, TC innovations need to address the right older target population, and transition roles for staff should be developed as key steps. LTC organizations can benefit from collaborating and leveraging concurrently their readiness for change along with adopting innovation management in order to succeed in implementing TC innovations. Furthermore, minimizing the confusion around how implementing innovation works holds the potential to improve care transitions for older persons.