ORIGINAL RESEARCH article
Front. Med.
Sec. Healthcare Professions Education
Volume 12 - 2025 | doi: 10.3389/fmed.2025.1632083
This article is part of the Research TopicDissemination and Implementation Science in MedicineView all 19 articles
Context and determinants for implementing a sepsis survivor care transition intervention reported from five health systems and home health agencies
Provisionally accepted
Kathryn H Bowles1,2,3*
Michael A Stawnychy1,3Melissa O'Connor4Mark E Mikkelsen5Nancy Hodgson1,3Elaine Sang1,3
Sang Bin You1,3Katherine Pitcher1,3
Jiyoun Song1,3
Sungho Oh1Brittany Newman6Patrik Garren1Charlotte Weiss1Karen B Hirschman1,3- 1Department of Biobehavioral Health Science, NewCourtland Center for Transitions & Health, University of Pennsylvania School of Nursing, Philadelphia, United States
- 2Center for Home Care Policy & Research, VNS Health, New York, United States
- 3Leonard Davis Institute of Health Economics, Philadelphia, United States
- 4Hunter-Bellevue School of Nursing, New York, United States
- 5University of Colorado Anschutz Medical Campus, Aurora, United States
- 6University of Pennsylvania College of Arts and Sciences, Philadelphia, United States
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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 one 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.
Keywords: Sepsis, implementation science, Care Transitions, Barriers & facilitative factors, Patient Transfer, Home Health Care (HHC), ICD- 10
Received: 13 Jun 2025; Accepted: 21 Oct 2025.
Copyright: © 2025 Bowles, Stawnychy, O'Connor, Mikkelsen, Hodgson, Sang, You, Pitcher, Song, Oh, Newman, Garren, Weiss and Hirschman. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Kathryn H Bowles, bowles@nursing.upenn.edu
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