Heterogeneity and misaligned incentives in discharge transition programs: Insights from a multisite rapid qualitative study

BACKGROUND: Transitions of care (ToC) programs are important for patient safety, but their implementation and success remain highly variable across US hospitals, particularly for patients with multimorbidity and health-related social needs (HRSNs). Hospitalists, as key decision-makers at discharge, encounter firsthand the factors that hinder the success of ToC programs. OBJECTIVE: To explore hospitalists' perspectives on successes, shortcomings, and implementation barriers in ToC programs, particularly during transitions from hospital to community settings. METHODS: Rapid qualitative study featuring virtual focus groups with participants from the Hospital Medicine Reengineering Network (HOMERuN). Data were analyzed using a mixed inductive-deductive framework to identify key themes. RESULTS: Twenty-two individuals from 19 different organizations participated in focus groups. None of the organizations offered comprehensive ToC programs to all patients. Four major themes emerged: (1) Diagnosis-specific ToC programs are effective but contribute to care fragmentation, particularly for patients with multimorbidity; (2) postdischarge follow-up is hindered by limited appointment availability, insurance barriers, and geographic challenges; (3) ToC programs often fail to address patient preferences, HRSNs, and health literacy, and lack adequate resources and leadership support; (4) successful programs require institutional commitment, dedicated funding, interprofessional collaboration, and community engagement. Participants emphasized the need to prioritize patient-centered care over financial return on investment. CONCLUSIONS: Current ToC programs are fragmented, undermining safe and equitable transitions. Addressing HRSNs, fostering leadership support, and prioritizing patient-centered care over short-term financial metrics are essential for improving ToC outcomes.