Abstract
Rapport and colleagues highlight the challenges involved in enabling viable transitional care services in a federated landscape, where different care providers are responsible for different aspects of patient care and where care organisations may need to work together to ensure smooth patient throughput, especially when patients are transitioning through different parts of the healthcare system. The chapter draws on examples from the Australian healthcare system when considering what a federated landscape of healthcare provision might mean. The authors describe challenges surrounding working in complex healthcare systems and the implementation of research into practice to ensure long-term results that can lead to appropriate healthcare reforms, clear clinical guidelines and resilient services.
Similar content being viewed by others
References
Amalberti, R., Nicklin, W., & Braithwaite, J. (2016). Preparing national health systems to cope with the impending tsunami of ageing and its associated complexities: Towards more sustainable health care. International Journal for Quality in Health Care, 28, 1–3.
Australian Bureau of Statistics. (2008). 4102.0 – Australian social trends, 2008. Canberra: ABS.
Australian Institute of Health and Welfare. (2014). Transition care for older people leaving hospital, 2005–06 to 2012–13. Canberra: AIHW.
Australian Institute of Health and Welfare. (2015). Australia’s hospitals 2013–14 at a glance. Health services series no. 61. Cat. no. HSE 157. Canberra: AIHW.
Axelrod, R., & Cohen, M. D. (2000). Harnessing complexity: Organizational implications of a scientific frontier. New York: Basic Books.
Boyd, C. M., Darer, J., Boult, C., Fried, L. P., Boult, L., & Wu, A. W. (2005). Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance. JAMA, 294, 716–724.
Braithwaite, J., Runciman, W., & Merry, A. (2009). Towards safer, better healthcare: Harnessing the natural properties of complex sociotechnical systems. Qual Saf Health Care, 18, 37–41.
Braithwaite, J., Clay-Williams, R., Nugus, P., & Plumb, J. (2013). Healthcare as a complex adaptive system. In E. Hollnagel, J. Braithwaite, & R. L. Wears (Eds.), Resilient health care. Farnham/Surrey: Ashgate.
Braithwaite, J., Marks, D., & Taylor, N. (2014). Harnessing implementation science to improve care quality and patient safety: A systematic review of targeted literature. International Journal for Quality in Health Care: Journal of the International Society for Quality in Health Care/Isqua, 26, 321–329.
Braithwaite, J., Matsuyama, Y., Mannion, R., & Johnson, J. (2015). Healthcare reform, quality and safety: Perspectives, participants, partnerships and prospects in 30 countries. Farnham/Surrey: Ashgate Publishing.
Braithwaite, J., Mannion, R., Matsuyama, Y., Shekelle, P., Whittaker, S., & Al-Adawi, S. (2017, in press). Health systems improvement across the globe: Success stories from 60 countries. Abingdon: Taylor & Francis.
Braithwaite, J., Mannion, R., Matsuyama, Y., Shekelle, P., Whittaker, S., & Al-Adawi, S. (forthcoming). Health systems improvement across the globe: Success stories from 60 countries. Abingdon: Taylor & Francis.
Cartwright, C., Wade, R., & Shaw, K. (2011). The impact of telehealth and telecare on clients of the transition care program. Lismore: Aged Services Unit, Health and Wellbeing Research Cluster, Southern Cross University.
Clay-Williams, R., Nosrati, H., Cunningham, F. C., Hillman, K., & Braithwaite, J. (2014). Do large-scale hospital- and system-wide interventions improve patient outcomes: A systematic review. BMC Health Services Research, 14, 1–13.
Coleman, E. A. (2003). Falling through the cracks: Challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatrics Society, 51, 549–555.
Duckett, S. (2015). Australia. In J. Braithwaite, Y. Matsuyama, R. Mannion, & J. Johnson (Eds.), Healthcare reform, quality and safety: Perspectives, participants, partnerships and prospects in 30 countries. Farnham/Surrey: Ashgate Publishing.
Eccles, M. P., Armstrong, D., Baker, R., Cleary, K., Davies, H., Davies, S., Glasziou, P., Ilott, I., Kinmonth, A.-L., Leng, G., Logan, S., Marteau, T., Michie, S., Rogers, H., Rycroft-Malone, J., & Sibbald, B. (2008). CERAG report: A report prepared for the high level group on clinical effectiveness by the clinical effectiveness research agenda group (CERAG). London: Clinical Effectiveness Research Agenda Group.
Gardner, K., Yen, L., Banfield, M., Gillespie, J., Mcrae, I., & Wells, R. (2013). From coordinated care trials to medicare locals: What difference does changing the policy driver from efficiency to quality make for coordinating care? International Journal for Quality in Health Care, 25, 50–57.
Giles, L., Halbert, J., Gray, L., Cameron, I., & Crotty, M. (2009). The distribution of health services for older people in Australia: Where does transition care fit? Australian Health Review, 33, 572–582.
Global Burden Of Disease Study 2013 Collaborators. (2015). Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: A systematic analysis for the global burden of Disease study 2013. The Lancet, 386, 743–800.
Gray, L. C., Peel, N., Crotty, M., Kurrle, S., Giles, L., & Cameron, I. (2012). How effective are programs at managing transition from hospital to home? A case study of the Australian transition care program. BMC Geriatrics, 12, 6.
Gray, L. C., Travers, C. M., Bartlett, H. P., Crotty, M., & Cameron, I. D. (2008). Transition care: Will it deliver? The Medical Journal of Australia, 188, 251–253.
Grimshaw, J., Eccles, M., & Russell, I. (1995). Developing clinically valid practice guidelines. Journal of Evaluation in Clinical Practice, 1, 37–48.
Grimshaw, J. M., Eccles, M. P., Lavis, J. N., Hill, S. J., & Squires, J. E. (2012). Knowledge translation of research findings. Implementation Science, 7, 1–17.
Hillman, K., Rubenfeld, G., & Braithwaite, J. (2015). Time to shut down the acute care conveyor belt? Medical Journal of Australia, 203, 429–430.
Hollnagel, E., Braithwaite, J., & Wears, R. L. (2013). Resilient health care. Surrey: Ashgate Publishing.
Hutter, B. M. (2001). Regulation and risk: Occupational health and safety on the railways. Oxford: Oxford University Press.
Katon, W. J., Lin, E. H. B., Von Korff, M., Ciechanowski, P., Ludman, E. J., Young, B., Peterson, D., Rutter, C. M., Mcgregor, M., & Mcculloch, D. (2010). Collaborative care for patients with depression and chronic illnesses. New England Journal of Medicine, 363, 2611–2620.
Lipsitz, L. A. (2012). Understanding health care as a complex system: The foundation for unintended consequences. JAMA, 308, 243–244.
Masters, S., Halbert, J., & Crotty, M. (2008). What are the first quality reports from the transition care program in Australia telling us? Australasian Journal of Ageing, 27, 97–102.
Mcdonald, R., Waring, J., Harrison, S., Walshe, K., & Boaden, R. (2005). Rules and guidelines in clinical practice: A qualitative study in operating theatres of doctors’ and nurses’ views. Quality and Safety in Health Care, 14, 290–294.
Naylor, M. D., Feldman, P. H., Keating, S., Koren, M. J., Kurtzman, E. T., Maccoy, M. C., & Krakauer, R. (2009). Translating research into practice: Transitional care for older adults. Journal of Evaluation in Clinical Practice, 15, 1164–1170.
Ogilvie, D., Craig, P., Griffin, S., Macintyre, S., & Wareham, N. J. (2009). A translational framework for public health research. BMC Public Health, 9, 1–10.
Parker, D., & Lawton, R. (2000). Judging the use of clinical protocols by fellow professionals. Social Science & Medicine, 51, 669–677.
Plant, N., Kelly, P., Leeder, S., D’souza, M., Mallitt, K., Usherwood, T., Jan, S., Boyages, S., Essue, B., Mcnab, J., & Gillespie, J. (2015). Coordinated care versus standard care in hospital admissions of people with chronic illness: A randomised control trial. Medical Journal of Australia, 203, 33–39.
Pricewaterhouse Coopers. (2007). The national evaluation of the second round of coordinated care trials. Canberra: Commonwealth of Australia.
Rapport, F., Jerzembek, G., Seagrove, A., Hutchings, H., Russell, I., Cheung, W.-Y., & Williams, J. G. (2010). Evaluating innovations in the delivery and organization of endoscopy services in England and Wales. Qualitative Health Research, 20, 922–930.
Rapport, F., Seagrove, A. C., Hutchings, H. A., Russell, I. T., Cheung, I., Williams, J. G., & Cohen, D. (2012). Barriers and facilitators to change in the organisation and delivery of endoscopy services in England and Wales: A focus group study. BMJ Open, 2, e001009. https://doi.org/10.1136/bmjopen-2012-001009.
Schoen, C., Osborn, R., How, S. K. H., Doty, M. M., & Peugh, J. (2009). In chronic condition: Experiences of patients with complex health care needs, in eight countries, 2008. Health Affairs, 28, w1–w16.
Seagrove, A. C., Alam, M. F., Alrubaiy, L., Cheung, W.-Y., Clement, C., Cohen, D., et al. (2014). Randomised controlled trial. Comparison of iNfliximab and ciclosporin in Steroid Resistant Ulcerative Colitis: Trial design and protocol (CONSTRUCT). BMJ Open, 4, e005091. https://doi.org/10.1136/bmjopen-2014-005091.
Sturmberg, J. P., O’halloran, D. M., & Martin, C. M. (2012). Understanding health system reform – A complex adaptive systems perspective. Journal of Evaluation in Clinical Practice, 18, 202–208.
Tricco, A. C., Antony, J., Ivers, N. M., Ashoor, H. M., Khan, P. A., Blondal, E., Ghassemi, M., Macdonald, H., Chen, M. H., Ezer, L. K., & Straus, S. E. (2014). Effectiveness of quality improvement strategies for coordination of care to reduce use of health care services: A systematic review and meta-analysis. CMAJ: Canadian Medical Association Journal = Journal De L’association Medicale Canadienne, 186, E568–E578.
Wears, R. L., Hollnagel, E., & Braithwaite, J. (2015). Resilient health care, volume 2: The resilience of everyday clinical work. Surrey: Ashgate Publishing.
Woods, D. D., Dekker, S., Cook, R., Johannesen, L., & Sarter, N. (2010). Behind human error. Surrey: Ashgate Publishing.
Author information
Authors and Affiliations
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2017 The Author(s)
About this chapter
Cite this chapter
Rapport, F., Braithwaite, J., Mitchell, R., Westbrook, J., Churruca, K. (2017). Transitional Care in a Federated Landscape. In: Aase, K., Waring, J., Schibevaag, L. (eds) Researching Quality in Care Transitions. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-319-62346-7_10
Download citation
DOI: https://doi.org/10.1007/978-3-319-62346-7_10
Published:
Publisher Name: Palgrave Macmillan, Cham
Print ISBN: 978-3-319-62345-0
Online ISBN: 978-3-319-62346-7
eBook Packages: Social SciencesSocial Sciences (R0)