Exploring interdependencies, vulnerabilities, gaps and bridges in care transitions of patients with complex care needs using the Functional Resonance Analysis Method

Abstract Background: Care transitions, such as a patient’s hospital discharge, are complex processes encompassing multiple interactions and requiring coordination between stakeholders. To identify potential improvement measures in care transitions for people with complex care needs, intra- and inter-organisational everyday work needs to be properly understood, including its interdependencies, vulnerabilities and gaps. The aim of this study was to map the coordination of care across healthcare and social care organisations and describe interdependencies and system variability in care transitions. Methods: The study was inspired by multi-method research. Data were collected through participant observations, interviews and a document review in a region of southern Sweden. The Functional Resonance Analysis Method was used to model the discharge process and visualise and analyse coordination within and between different organisations and units. Results: The results show that hospital discharge is a time-sensitive process with numerous couplings and interdependencies where healthcare professionals are constrained by system design and organisational boundaries. The greatest vulnerability can be found when the patient arrives at home, as maladaptation earlier in the care chain can lead to an accumulation of issues for the municipal personnel in social care working closest to the patient. The possibilities for the personnel to adapt are limited, especially at certain times of day, pushing them to make trade-offs to ensure patient safety. To counteract variability in performance of care, flexibility and adequate resources need to be ensured, to promote the possibility to respond and adjust to uncertainties. Conclusions: To achieve safe and secure care transitions from hospital to home, proactive work during discharge planning needs to be facilitated by improving the timing and precision in assessment and planning of patient care. Responding to unexpected events and variations requires successful adaptation and use of allocated resources during the first few days after homecoming, and a system allowing for flexibility to promote safe and personalized care.