Context and determinants for implementing a sepsis survivor care transition intervention reported from five health systems and home health agencies

Abstract

Introduction:

Care transitions from acute to post-acute care are complex, especially for sepsis survivors. Implementation science offers valuable insights to translate best practices and improve care transitions. Our objective is to explore the context (site characteristics and personnel) and determinants (barriers, proposed strategies, and facilitators) influencing I-TRANSFER, a Type 1 hybrid implementation science study aimed at providing timely home health and outpatient visits for sepsis survivors within 1 week of hospital discharge.

Methods:

Qualitative, descriptive design with interviews guided by the eight study objectives and the Consolidated Framework for Implementation Research. Ninety-one leaders in clinical, quality, and administrative roles caring for sepsis survivors in five healthcare systems (16 hospitals) and five affiliated home health care agencies in four states participated. Deductive and inductive thematic analysis of 61 interviews conducted using NVivo 14. Proposed strategies were mapped to the Expert Recommendations for Implementing Change (ERIC) taxonomy.

Results:

A total of 32 themes emerged. Barriers included care coordination, staffing, electronic health record (EHR), information transfer, and access to care. Informants proposed ERIC strategies to address barriers such as changing record systems, facilitating relay of clinical data to providers, conducting education meetings, or revising professional roles. Facilitators occurred across several themes: EHR; information transfer; staffing; care coordination; access to care; home health policies, pathways, and processes; and quality monitoring.

Conclusion:

The interviews produced actionable insights for leaders, clinicians, providers, and policy makers regarding identifying sepsis through clear definitions, using the problem list and ICD-10 coding. Scheduling outpatient care, communicating to the next level of care, and providing timely follow-up and care coordination necessitates attention to staffing, tools for scheduling and quality measurement, and EHR integration for information transfer. Patient education is critical for awareness of risk and informed decision-making regarding follow-up after discharge.

1 Introduction

The evidence base for effective care transitions post-hospital discharge is well established (1, 2), yet there is limited knowledge about implementation barriers (3, 4), facilitators, or strategies (3, 5). Evidence-based care transition interventions ensure optimal continuity of care for patients moving between healthcare settings (1). However, the current lack of knowledge about the context and determinants of successful care transition implementation can lead to repeated errors, wasted resources and time, and inconsistent implementation quality (6). Communicating barriers and facilitators is essential for advancing implementation science and translating evidence to practice (7).

Care transitions are inherently complex and fraught with challenges such as fragmented (1) or delayed care (8), poor communication, and insufficient information exchange (9). The period immediately following hospital discharge is critical, especially for high-risk conditions like sepsis (10). Sepsis patients experience life-threatening organ dysfunction caused by a dysregulated immune response to infection (11). While improved recognition and rapid treatment have increased survival rates (12), sepsis is still the leading cause of 30-day readmission (13) and survivors frequently experience post-sepsis syndrome (14, 15), reinfection (16), and exacerbation of chronic conditions (10). Among sepsis survivors transitioned to home health care (HHC), 32% of 30-day readmissions occurred within the first week (17), underscoring the need for implementation of evidence-based care transition protocols.

The I-TRANSFER (Improving TRansitions ANd OutcomeS oF SEpsis SuRvivors) implementation science study (2R01NR016014) examines the implementation and effectiveness of a best practice protocol to reduce 30-day readmissions for sepsis survivors (18). The evidence-based protocol, developed in a previous comparative effectiveness study (19), involves a HHC start-of-care nursing visit within 2 days of hospital discharge, an additional nursing visit, and an outpatient provider visit within the first week post-discharge. Sepsis survivors who received this protocol had 30-day readmission rates 7% lower than their counterparts; a 41% relative reduction (19). However, only 28% of sepsis survivors nationwide received this pattern of care (19).

Prior to I-TRANSFER implementation, a needs assessment was conducted to assess the context and determinants of implementation. Here, we report our findings and discuss them in the context of other care transition implementations, the Centers for Disease Control (CDC) Hospital Sepsis Program Core Elements (20) and provide implications for practice, research, and policy.

2 Materials and methods

2.1 Study design

We used a qualitative descriptive design with individual and group needs assessment interviews guided by the eight objectives (obj) of the I-TRANSFER protocol (Figure 1). Interviews also considered the five domains of the Consolidated Framework for Implementation Research (CFIR): Innovation, Outer Setting, Inner Setting, Individuals, and the Implementation Process (21), and context-site characteristics, roles, and circumstances (22). Determinants include barriers that hinder achieving protocol objectives, proposed strategies to overcome them, and facilitators that support implementation (22). Proposed strategies were organized using the Expert Recommendations for Implementing Change (ERIC) taxonomy (23).

Figure 1

2.2 Setting and subjects

To support transferability (24), sites were purposefully selected for variation in size, location, and integration (hospital and HHC under the same system). Leaders in clinical, quality, or administrative roles from five healthcare systems and five affiliated HHC agencies (“dyads”) were recruited by the Principal Investigator (PI) (KHB). Site leaders identified a purposeful sample (25) of individuals involved in sepsis care and transitions to HHC and outpatient care. Chain-referral sampling was used to recruit additional informants (26).

The study was approved by two Institutional Review Boards (University of Pennsylvania School of Nursing and VNS Health) and informants provided verbal consent. Methods and results are reported in accordance with the COnsolidated criteria for REporting Qualitative research (COREQ) checklist (27) (Supplementary Table 1).

2.3 Data collection

Following consent, (KHB, MOC, and MS) conducted 60-min, semi-structured Zoom interviews between May and November 2021 with one additional group interview in June 2022 when one hospital joined later. The interview guide was published previously (28). Interviews were recorded, transcribed, cleaned and de-identified by trained research assistants, and uploaded to NVivo 14 for analysis (29). Field notes captured context and role descriptions. Data saturation was reached when context and process were fully described.

2.4 Data analysis

The analytic team included the PI (KHB), three Co-Investigators (MOC, NH, KBH), postdoctoral fellows (MS, SO, CW) and pre-doctoral students (ES, MGT). Research team members trained together applying thematic analysis (30) to create an initial codebook and deductively code four random transcripts, achieving 90% agreement. Independent coding followed, with 20% of interviews double coded for intercoder reliability (range 91–97%). Weekly meetings refined the codebook. Inductive thematic analysis coded the barriers and facilitators into themes. The proposed strategies were mapped to the ERIC taxonomy (23) by (CW) and confirmed by consensus with (KHB and MOC). Findings were reported back to the informants for member-checking (credibility) (31). Detailed notes and site/informant characteristics enhanced transferability (31, 32). Results were discussed with our National Advisory Committee, comprised of experts in sepsis and HHC, to increase credibility and transferability (31).

3 Results

3.1 Context- informants

A total of 91 informants participated in 61 interviews: 36 individual and 25 group interviews with 57 informants from acute care and 34 from HHC or outpatient care. Informants’ roles included administrators, care and intake coordinators, hospitalist and intensivist physicians, advanced practice nurses, quality managers and coders, clinicians with roles in direct care delivery, and sepsis coordinators.

3.2 Context- site characteristics

The I-TRANSFER study includes five health systems with 16 hospitals, paired with five HHC agencies (five dyads) in four states. Nine hospitals are in large academic medical centers (dyads 1, 4, 5), seven are community-based (dyads 2, 3) with medium and small bed sizes, respectively. Three HHC agencies (dyads 1–3) are owned by the partnering health system (integrated); two are independent (dyads 4, 5). Table 1 provides descriptives of the informants and sites.

3.3 Themes

Qualitative coding of the barriers, proposed strategies, and facilitators discussed in the interviews resulted in 32 themes listed and defined in Table 2. Below, we indicate themes and (subthemes) in italics reported as barriers and facilitators. Figures 2, 3 provide summaries of the barriers and facilitators for each objective. Exemplary quotes illustrating barriers and facilitators are provided in Table 3 for acute care objectives 1–5 and Table 4 for HHC objectives 6–8. To protect confidentiality, quotes are labeled by the site of the informant (e.g., acute care) rather than the role of the person since some sites had one person in a particular role (e.g., sepsis coordinator).

Figure 2

Figure 3

3.4 Barrier themes and (sub-themes)

Care coordination became difficult if the sepsis diagnosis was not clearly documented in the medical record. This arose when sepsis was either not diagnosed, not documented, or was resolved at discharge and fell to the medical history, rather than carrying forward as a condition requiring ongoing care. Multi-morbidity added complexity to the focus of care and there was variation in the operational definition of sepsis [Systemic Inflammatory Response Syndrome (SIRS), Sequential Organ Failure Assessment (SOFA)], Centers for Medicare and Medicaid Sep-1, which ascribes to Sepsis 2 definition, or Sepsis-3 (11, 33). When discussing how sepsis is documented in the EHR, barriers included competing diagnoses, difficulty identifying or over-identifying sepsis patients, and failing to use the word “sepsis.” Inconsistent use of the problem list in the EHR was a barrier to identifying sepsis with variation on how (e.g., sepsis as a resolved problem), or if the problem list was used at all. This had a cascading effect on information transfer to the next level of care and the ability to trigger the I-TRANSFER protocol.

Care coordination and information transfer posed challenges between acute and HHC, particularly with non-integrated EHRs and inconsistent or varied avenues for communication. Barriers included receiving too much or too little information, difficulty in finding sepsis diagnoses, and a lack of standardized communication. Post-acute HHC informants found it frustrating to receive multiple messages via texts, calls, or instant messaging, or to have no information at all. HHC informants noted they could not document sepsis if labeled resolved at discharge. Scheduling the first HHC visit and outpatient appointment before discharge and ensuring attendance were seen as care coordination and staffing challenges.

Informants unanimously supported the need for timely outpatient follow-up but identified a complex interplay of barriers to scheduling and access to care such as no one assigned to do it (staffing), where the patient lives and what takes precedence in their lives (geographic location, social determinants of health), appointments made without patient or caregiver input (provider or staff behavior), scarce availability of open appointments or lack of access to outpatient schedules (access to care), conflicting information in discharge instructions (patient education), lack of transportation, and attempts to avoid co-pays (competing priorities, financial insurance). Patient behavior, decisions, and preferences to decline or delay HHC, not arrange or keep their outpatient appointments (no-show outpatient), prohibited timely care.

Staff shortages (staffing) in acute and HHC added to the challenges, particularly the ability to: find those who need HHC referrals, make outpatient appointments prior to discharge, and have enough HHC nurses to conduct the timely start of care or second visits. Severe staffing shortages and geographic location of the patient’s home affected whether a HHC agency accepted a patient.

3.5 Proposed strategies

Informants proposed strategies to overcome barriers to implementing the I-TRANSFER protocol. In ERIC taxonomy terms, some examples include changing record systems to create a banner or flag in the EHR to communicate sepsis survivors. The strategy to facilitate relay of clinical data to providers was often suggested in discussions of workflow in the home care referral and the discharge process. Other strategies suggested were to use data warehousing techniques to create reports to track patients throughout the transition and intervening with patients to enhance uptake and adherence through education, as well as involve patients and family members when making the outpatient appointment. Supplementary Table 2 reports proposed strategies, mapped to the ERIC taxonomy (23) and linked to the barrier theme and objective it addresses.

3.6 Facilitator themes

Prediction models and decision tree checklists within the EHR supported providers in identifying and diagnosing sepsis (definition of sepsis). The use of EHR add-on third-party software helped patients choose a quality HHC agency in their location. With the use of the problem list, the EHR facilitated patient education by populating education materials and documenting follow-up appointments in the after-visit summary (AVS) sent home with the patient. Integrated EHR systems facilitated information transfer across care settings. Software facilitating information transfer on the HHC referrals reduced phone calls and messaging. All HHC sites had at least a view into the acute care EHR.

Quality monitoring of service, including provider documentation, was a facilitator toward identifying the sepsis survivor in acute care. All sites had clinical documentation improvement (CDI) teams who monitored the EHR for signs and symptoms of sepsis (manually or via natural language processing) and queried providers to confirm or refute a sepsis diagnosis. The CDI team facilitated adding sepsis to the problem list, triggering daily reports to alert care coordinators, promoting information transfer to the next level of care, and prompting sepsis-specific patient education.

Staffing, in the form of full-time or part-time sepsis coordinators facilitated many of the I-TRANSFER objectives such as confirming the sepsis diagnoses, communicating sepsis to the team and patient, advocating and making post-acute care referrals, patient education, and scheduling outpatient appointments. One hospital used unit clerks to work with patients and caregivers to schedule outpatient appointments. One HHC agency reported increasing staffing on Friday–Sunday to handle surges in hospital discharges on Thursdays and Fridays. Sites also described augmented services (paramedic visits, home visiting providers, advanced illness management programs) to facilitate outpatient contact after discharge.

Care coordination was facilitated when the discharging provider signed the HHC orders for those without an outpatient provider. Few participating HHC agencies had liaisons in the hospitals as they were discontinued during the COVID-19 pandemic and not reinstituted, but when there was a HHC liaison on staff, they were described as a facilitator to make the HHC referral, schedule the first home visit, and coordinate services and equipment delivery. Acute care coordinators (staffing) assess discharge planning needs on each patient, and all sites had them (acute care policies, pathways, and processes).

Access to care was facilitated at sites with outpatient coordinators or in sites involved in the bundled payment program (external policies and incentives) because they are incentivized to increase quality and care coordination for 90-days. Designated personnel were responsible for ensuring HHC started after discharge and confirming patients had their medications, outpatient appointments, and transportation. Having Medicare insurance was another access to care facilitator and telemedicine emerged as a solution for outpatient appointments. Hospital at Home provider visits facilitated outpatient follow-up for the homebound (augmented services).

The presence of an informal caregiver facilitated sepsis education and the importance of timely post-acute attention. Informants mentioned calling from the bedside and using Facetime to educate caregivers.

Home health internal policies, pathways, and processes were compatible with I-TRANSFER HHC objectives. All the HHC leaders explained that ongoing efforts to comply with Medicare standards for the timely start of HHC and industry conventions for frontloading visits would facilitate the I-TRANSFER protocol.

4 Discussion

Barriers, proposed strategies, and facilitators were revealed during interviews to form 32 themes. Care coordination and staffing were the most saturated themes for barriers as they affected all eight I-TRANSFER objectives. Inadequate staffing for necessary tasks or visits was pervasive across all settings and sites, while having a sepsis coordinator or HHC liaison in place was advantageous. Care coordination and access to care themes contained barriers to getting an appointment and making and keeping the outpatient appointment within 7 days. The EHR was both a barrier and a facilitator for identifying sepsis, communicating sepsis, and coordinating sepsis care. The task of information transfer across settings faced several barriers but also had many facilitators in place and strategies for improvements were proposed. Home care internal policies, processes and pathways were compatible with I-TRANSFER in promoting the timely start of care and first week nursing visits. We situate our findings in relation to the literature and guidance from the Hospital Sepsis Program Core Elements (20).

To activate any intervention for sepsis we must first accurately identify and adequately document the sepsis diagnosis; in line with our objective 1. Establishing a standard definition of sepsis such as Sep-3 recommended by the Society of Critical Care Medicine and the European Society of Intensive Medicine (11) could help to address the serious information transfer and sepsis surveillance issues revealed by our study and others (34). The CDC Core Elements recommend standardized sepsis definitions, templated notes to document sepsis diagnosis and treatment, and inter-facility infection control transfer forms as processes to assure safe patient transfer (20). Facilitators present in our sites and the literature such as EHR algorithms, alerts, checklists, screening tools, and NLP are helpful to detect sepsis, but more work is needed to improve their accuracy and gain trust (35), reduce alert fatigue (36), and ensure their timeliness in the workflow (37).

A scoping review of 21 care transition intervention studies revealed parallels to our findings (1). Disrupted information flow negatively impacted care coordination and the transfer of information (4, 38, 39). Like other studies, our assessment found inconsistent use of the problem list (40, 41). This affected the ability to flag sepsis survivors for I-TRANSFER and ensure patients, informal caregivers, and providers were aware of the patient’s risk for rehospitalization and new or recurrent infection (42). Furthermore, identifying survivors in HHC was impeded by coding practices. HHC Coders were reluctant to place an acute care diagnosis of sepsis on the patient record if marked as resolved or not clearly documented as the reason for HHC. They reported they had no other code to use, so they labeled sepsis survivors as “other aftercare.” Based on this discovery, our team successfully petitioned the Centers for Disease Control for a post-acute ICD-10 code Z51. A Encounter for Sepsis Aftercare (43, 44). Acute care providers should optimize use of the problem list and educate teams to include the new aftercare code in discharge documents to enhance communication about sepsis survivorship and as a strategy to reconcile the effect of sepsis being reported as resolved on the problem list when aftercare is warranted to manage or rehabilitate new, lingering, or worsening sepsis-related problems. Incorporating this code in discharge documents can support improved information transfer and help identify sepsis survivors and trigger timely, sepsis focused interventions during the critical recovery period (our objectives 4, 6, 7, 8). Using the new code in post-acute settings will improve surveillance and tracking of sepsis survivors, enabling longitudinal study of sepsis survivors across care settings and time. This will deepen our understanding of the true burden of sepsis (34).

Our work reports barriers to optimal sepsis care in all six dimensions suggested by Draeger and colleagues (45) in their systemized review of 50 sepsis studies. Transitioning sepsis survivors for timely HHC and outpatient care is a complex process that requires communication, collaboration, and coordination across settings. One study identified 31 tasks associated with just the HHC referral process placing a burden on both acute and home health care staff (46). Staffing barriers included short staffing (47, 48), lack of dedicated staff (4), no sepsis coordinator or personnel to make outpatient appointments, and overwhelmed care managers (49, 50). The Hospital at Home program similarly faced care coordination and information transfer challenges due to non-integrated EHR’s (4).

Multiple care transition studies report the role of a transition nurse, social worker, coach, or care coordinator as a facilitator (1, 48, 51). In our study, sites with a sepsis coordinator identified them as a strong facilitator for implementing I-TRANSFER objectives, especially objectives 2–5 (identifying and referring patients for HHC, transferring information, making appointments). Sepsis coordinators could also facilitate implementation of the sepsis aftercare code, for the aforementioned reasons. In a pre-post evaluation of 13,877 patients, a multi-level quality improvement program with a sepsis coordinator proved sepsis coordinators cost effective with decreased mortality and length of stay (52). A systematic review of studies focused on the care transition experiences of patients, family members, and health care professionals reported seven out of 12 studies found that having an experienced case manager coordinating care facilitated intervention success (53).

An unexpected finding was how home health care internal policies, pathways, and processes were powerful facilitators of timely home health admission (our objective 6). The HHC industry standard to frontload visits for high-risk populations (54) and Medicare policies for a timely start of care within 2 days of discharge align with I-TRANSFER objectives. The Care Transitions Framework (CTF) (55) also supports these findings providing constructs for implementing care transitions innovations. Further, the Organizational Readiness to Implement Change survey of our sites revealed that HHC agency implementors were significantly more ready than acute care, perhaps due to existing policies and processes (56).

The Comprehensive Post-Acute Stroke Services Study (COMPASS-TC), which tested a hospital-to-home and outpatient care transitional care model (3), reported similar barriers to us including difficulty identifying eligible patients, insufficient staffing, lack of tracking systems/reports, clinic no-shows, and limited appointment availability (3). Insufficient insurance coverage and competing priorities like food and utilities may prevent patients from accepting home health or outpatient services due to co-pays. Screening for social determinants of health is recommended to identify and address these barriers (20). Addressing patient behavior, decision-making, and education is critical, as those unaware of, or unwilling to acknowledge their care needs may decline services and not seek care when needed (39, 51).

The CDC core elements emphasize communicating the sepsis diagnosis to primary care; we recommend expanding this communication to all post-acute settings, as well as to patients and caregivers. Diagnostic disclosure and patient education are essential- nearly half of sepsis survivors in a 2015 study were unaware of their diagnosis and associated risks (57). More research is needed that focuses on the educational and social needs of the patients and caregivers.

Outpatient care coordination and transition programs that contact patients after discharge were common facilitators at our sites. Home health clinicians followed established policies to ask about follow-up appointments and transportation, and they assisted with telemedicine visits when needed. However, for interventions like I-TRANSFER, calling within a week after discharge will be too late to ensure timely start of HHC or attendance at outpatient appointments. Our previous national study of sepsis survivors in HHC found that only 11% received outpatient visits within 1 week of discharge (19), compared to the AVENIR cohort in Germany where 68.8% of sepsis survivors saw a general practitioner within 2 days and 80% within 4 days (58). These comparisons highlight the urgent need to accelerate outpatient care timelines for sepsis survivors in the United States.

Although very challenging, care coordination interventions and protocols with multiple approaches to care transitions for sepsis survivors have resulted in improved rates of mortality, readmission, long-term physical function, and post-traumatic stress disorder symptoms (59). Aiming for similar results with the I-TRANSFER protocol, our next steps are to conduct and evaluate the implementation. We will perform implementation mapping (60) with the stakeholders to leverage the facilitators, operationalize the proposed strategies, and develop additional strategies to address the barriers we identified as implementation proceeds. During the implementation we will track the strategies implemented and quantify the effect of the implementation on readmission, ED use, and timeliness of care (18).

4.1 Limitations

The study is limited to five health systems (16 hospitals) and five HHC agencies in the northeast and western regions of the United States. The perspectives do not include sepsis survivors or their caregivers. Also, this analysis does not examine the relationship among specific sites, informant characteristics, and the determinants discussed. Future work will include more in-depth descriptions of certain themes and subthemes, analysis of the relationships between site characteristics, significant events affecting implementation, and the effects of the implementation on 30-day readmission.

5 Conclusion

A comprehensive needs assessment with 91 informants from acute, home health, and outpatient care revealed 32 themes containing barriers, proposed strategies, and facilitators critical to understand and address prior to implementation of a timely HHC and outpatient visit protocol for sepsis survivors. The interviews produced actionable insights for leaders, clinicians, providers, and policy makers regarding identifying sepsis through clear definitions, using the problem list and ICD-10 coding. Scheduling outpatient care, communicating to the next level of care, and providing timely follow-up and care coordination necessitates attention to staffing, tools for scheduling and quality measurement, and EHR integration for information transfer. Patient education is critical for awareness of risk and informed decision-making regarding follow-up after discharge.

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