Introduction

Hospital-to-home transitional care (TC) refers to healthcare services provided to patients to ensure their care needs continue to be met after discharge home. In response to high rates of hospital readmissions of older patients with complex health conditions, TC has become a health systems priority in many jurisdictions [1,2]. Nowhere is this more a priority than in rural communities. Compared to urban communities, rural communities have greater proportions of older people (aged 60+) [3,4] and people living with multiple chronic conditions (≥ 2 concurrent chronic conditions)[4,5], which are risk factors for hospital readmission [6,7]. Indeed, rural dwellers have significantly higher rates of emergency department visits and hospital readmissions during the 30-day post-discharge period, and up to 59% of their hospital readmissions are considered avoidable [8].

TC commences in hospital and is usually provided by nurses in conjunction with the interprofessional team [9]. TC models typically emphasize the importance of adequately preparing patients to recognize and respond appropriately to the signs that their health may be worsening [9,10]. A systematic review of TC trials concluded that a warning signs intervention, as part of multicomponent TC programs, is associated with decreased visits to the emergency department and fewer readmissions to the hospital [9].

Based on a literature synthesis, we devised a warning signs intervention aimed at helping patients and their families recognize and respond to the signs of worsening health [11]. The intervention begins with an in-hospital assessment of patients’ and families’ health literacy, their knowledge of the signs of worsening health relevant to the patient’s condition(s), their capacity to recognize and respond to the signs at home, and their learning needs [11]. The intervention is delivered both prior to and after hospital discharge. To promote its adoption, the intervention includes educational strategies such as the ‘teach-back’ method and written materials with symbols or pictograms to facilitate comprehension of how to monitor health and identify and respond to the signs of worsening health, such as which signs constitute a medical emergency and the need to seek immediate medical assistance [11].

Older rural medical patients at risk for hospital readmission and their families have highlighted that knowing how to detect and respond to the signs of worsening health is their most pressing unmet TC need [12,13]. They emphasized having received little preparation on how to recognize and respond to these signs, and needing more preparation in this regard. These findings parallel other studies indicating that 41% of patients discharged from hospital are unaware of the signs that their health may be declining [14]. Medical patients who do not know what signs to monitor after hospital discharge are almost 3.5 times more likely to visit the emergency department or be readmitted to hospital compared to those who know what signs to monitor [15]. Given the global trend toward shorter hospital stays and early discharges, older medical patients are likely to be discharged when their acute conditions are not fully resolved [16]. Consequently, there is an urgent need to better prepare such patients and their families for recognizing and responding to signs of worsening health to prevent adverse health consequences that require hospital readmission. Yet, little is known about healthcare professionals’ (HCP) perspectives on potential barriers and facilitators to implementing a warning signs intervention.

Previous research has examined barriers to TC in general (e.g., lack of expertise [17], fractured communication [18]) as well as facilitators (e.g., use of a pre-discharge check list, [17,18] strong interprofessional collaboration [18]). However, prior research has not explored HCPs’ perspectives on barriers and facilitators to implementing a warning signs intervention, particularly in rural communities where such interventions are urgently needed to prevent avoidable patient deterioration in health and unnecessary hospital readmissions. Building knowledge in this area is essential to knowing how to support HCPs in delivering the intervention, thereby optimizing TC in rural communities. Consequently, this study aimed to identify HCPs’ perspectives on barriers and facilitators to providing a warning signs intervention proposed for rural TC with older rural medical patients at risk for hospital readmission and their families.

Materials and methods

Results

Analysis by HCP strata revealed nine categories of barriers and facilitators: material resources; human resources; HCP communication; HCP knowledge & skill; HCP buy-in; context of rural practice; patient- and family-specific characteristics; HCP risks and liabilities; and timing of intervention delivery. Seven categories converged across HCP strata (see Table 1). However, the reasons why different HCP strata perceived the categories as important, and the ways in which they saw them functioning as barriers and facilitators, sometimes varied. Four categories of barriers and facilitators were only identified by two HCP strata. Below, we examine each category in turn. Individual HCP characteristics are outlined in Table 2, and illustrative quotes are presented in Table 3. We indicate where findings are specific to one HCP stratum; references to “participants” or “HCPs” denote all HCP strata.

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Table 1. Barriers and Facilitators to Implementing the Warning Signs Intervention by Healthcare Professional Stratum.

https://doi.org/10.1371/journal.pone.0322138.t001

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Table 2. Healthcare Professional Demographic Characteristics.

https://doi.org/10.1371/journal.pone.0322138.t002

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Table 3. Exemplar Quotes.

https://doi.org/10.1371/journal.pone.0322138.t003

Discussion

Our findings shed much-needed light on barriers and facilitators that should be considered to ensure successful implementation of the warning signs intervention in rural TC. Such understanding is needed for successful implementation [40]. Below, we discuss our key findings in the context of the existing literature and their implications for future practice, policy, and research.

In terms of human resources, it is notable that early discharges and shorter hospital stays are a worldwide trend. Since 2011, the average length of hospital stay has decreased in 36 of the 38 Organization for Economic Cooperation and Development countries [16]. Current emphasis on early hospital discharge requires HCPs to deal with high patient turnover, which increases workload related to admission and discharge [41]. Our sample of HCPs had an average of 14 years working in their professions. Consequently, they have witnessed firsthand the trend toward shorter hospital stays – and the associated increased patient turnover – and are familiar with the challenges of devoting more of their workday to preparing patients for discharge and/or following up with them after discharge. It is therefore not surprising that HCPs identified that human resources would be a barrier to delivering the warning signs intervention and suggested ways to enhance their ability to provide the intervention, such as reallocating their non-clinical tasks to administrative personnel.

Other research has found that costs remain a barrier to hiring the additional staff required to deliver TC interventions [40,42]. Nonetheless, evidence suggests that the increased cost of implementing the warning signs intervention may be countered by cost recovery from consequent reductions in hospital readmissions [43].

The issue of financial constraints was also evident amongst physicians who identified that the time to provide the education required of the warning signs intervention is at odds with their remuneration structure as well as expectations of quickly diagnosing and treating patients. These findings concur with other research emphasizing that remuneration is an obstacle to physicians adopting new practices. Mitra et al., for instance, emphasized that Ontario physicians view fee-for-service models as incentivizing them to quickly treat high volumes of patients and were frustrated that fee-for-service structures did not keep pace with practice change expectations [44]. Our study demonstrates that physicians are not incentivized to provide the intervention, but also underscore an ethical tension between physician financial remuneration policies and best practices. It is worth pondering what harm might come to patients when physicians do not provide the warning signs intervention, and the potential costs in the form of readmissions, adverse events, as well as burnout of physicians who may feel they are not providing the best possible care.

Our findings on HCP knowledge and skill highlight the training that HCPs require (e.g., what constitutes a warning sign for a particular health condition, how to use the teach-back method) and that allied HCPs, in particular, may benefit from training to successfully implement the intervention. Other research has likewise reported that failing to provide initial training in implementing new TC interventions impedes implementation [45]. Also, TC interventions in research studies are typically delivered by HCPs with additional training [10]. Consequently, providing HCPs with additional training should be a standard part of implementation; failing to provide an intervention as originally designed can result in low intervention uptake and effectiveness [46]. However, we found little research identifying what knowledge and skills HCPs need to successfully implement warning signs interventions.

A novel finding of our study is the need for HCP training on what constitutes a warning sign for a specific condition and the need for standardized, condition-specific (e.g., Congestive Heart Failure, Chronic Obstructive Pulmonary Disease) warning signs teaching materials. While such materials were proposed for patients and their caregivers, these could also benefit HCPs who lack knowledge of the warning signs of a particular health condition. Other research has likewise reported that HCPs’ ability to implement TC interventions is facilitated by their access to related knowledge and information [18].

Previous research has underscored that HCPs are often unable to prioritize TC because of high patient acuity and limited time, which challenge communication [47]. For example, hospital-based HCPs may experience difficulties coordinating care amongst interprofessional team members who work in the community [47]. TC requires different team members to communicate, which may be challenging in fast-paced practice environments [48]. Consequently, it is understandable that intra- and inter-sectoral communication was seen as a potential barrier to providing the intervention. Our findings illuminate potential facilitators that may mitigate this barrier, such as using checklists as communication tools among HCPs to track what warning signs education still needs to be provided and who is responsible for doing so. Although checklists and communication tools have been identified as facilitating TC more generally [17,18], to the best of our knowledge, they have not been identified as facilitating intra- and inter-sectoral communication surrounding warning signs interventions.

In the same vein, participants’ discussion of the lack of a shared electronic medical record (EMR) as a significant barrier to intersectoral communication stands to further complicate the sharing of information. In Canada, health care is administered by its 13 provinces and territories [49]. In the province of Ontario, not only is there variability among the EMRs that are used across sectors, but there is also variability among EMRs within a given sector because healthcare organizations are generally free to choose which EMR they use based on minimum technical specifications and provincial pre-certification. For example, OntarioMD lists 13 different EMR versions or platforms as certified for use in primary care as of its last posted update on March 26, 2024 [50]. We are not aware of any current policy direction in Ontario to consolidate EMRs or mandate a single EMR for use across all sectors. Therefore, our finding that different sectors chart on different EMRs and thus cannot share notes with each other adds to the evidence suggesting that a major policy shift is needed that prioritizes inter-sectoral communication. This is especially important given that research conducted in Denmark has identified that shared EMRs improve intersectoral HCPs’ ability to communicate in transferring information between sectors [51]. Other research has identified that EMRs are underutilized but, unlike our study, did not pinpoint the reasons why [10].

Regarding risks and liabilities, a unique finding of this study is that allied HCPs were concerned about disciplinary action from their professional regulatory College if they delivered the warning signs education because they perceived it as beyond their scope of practice. They maintained that healthcare administrators should not expect allied HCPs to deliver the warning signs intervention independently, but rather have allied HCPs support the education delivered by nurses or physicians. It is plausible that allied HCPs were resistant to performing tasks that, based on their training and professional socialization, they see as beyond their scope of practice. Prior research has identified that it is stressful for HCPs to be redeployed to new units or areas that are outside their scope of practice or beyond their usual duties [52]. Yet, previous research, such as a systematic review conducted by Leong et al. (2021) has also stressed that allied HCPs can successfully learn to adopt expanded roles for tasks such as patient and family education [53].

Both allied HCPs and physicians also expressed liability concerns about permitting patients and families to audio- or video-record the education provided about warning signs. However, liability insurers construe recordings as a safeguard to protect physicians from malpractice lawsuits [54], and there are few legal grounds to refuse patient requests to record their conversations with medical professionals [55]. In contrast to physicians and allied HCPs, nurses did not raise concerns about risks and liabilities. Although further research is needed, it is plausible that, unlike allied HCPs, nurses saw the warning signs intervention as within their scope of practice, which may explain why nurses did not identify risks and liabilities as a barrier.

Our findings that achieving buy-in from all interested parties (e.g., clinicians, managers, administrators) may be a barrier and that providing evidence on the potential outcomes and targeting champions to trial the intervention may facilitate widespread uptake generally concurs with other research [40,45]. However, a novel finding of our study is that nurses expressed that achieving nurse buy-in should not be problematic because they would recognize the potential benefits of the warning signs intervention. This finding suggests that potential champions to lead implementation of the warning signs intervention can be found amongst nurses.

Finally, our finding that aspects of the rural context – specifically, long distances and inclement weather preventing home visits – present barriers to delivering the intervention both reinforces and expands our understanding of rural contexts of practice. On the one hand, this finding highlights the persistence of longstanding challenges tied to rural geography and insufficient rural human health resources, which are well-documented in the literature [56–58]. On the other hand, our study shows how the rural context extends to hospital-to-home TC specifically, which is only beginning to be examined within the literature [12,26,59–61]. It is important that rural patients know what warning signs to monitor because between 23% and 33% of patients experience complications within six weeks of hospital discharge [62].

Strengths and limitations

Our study addresses a significant gap in TC research. A recent scoping review identified that 11 studies have explored barriers and/or facilitators to implementing hospital-to-home TC; however, all focused on TC in general [45]. None examined the warning signs intervention component of TC or were conducted in rural settings, and very few included physicians [45]. Since most prior TC research has not included physicians [45], we believe their inclusion, although limited, was a major strength of our study. Our study also included HCPs from different professions and sectors, which provided an enhanced, interprofessional understanding of barriers and facilitators to implementing the warning signs intervention. It is one of the few studies that focus exclusively on rural communities contributing to a small but growing interest in rural healthcare professionals’ perspectives on barriers and facilitators to implementing interventions.

In terms of limitations, although the allied HCP strata was comprised of a variety of professionals (e.g., social workers, occupational and physical therapists), we did not directly compare their perspectives. It is possible that apprehensions about lacking knowledge and skill to deliver the intervention may differ across professions. For example, this concern may be more common for social workers than physiotherapists. The same can be said for worries about risking disciplinary action from professional regulatory Colleges. The study was conducted in healthcare jurisdictions in one Canadian province; however, the rural and rural-serving jurisdictions from which we recruited are typical of rural health care services in rural North America [63]. Consequently, the findings are likely to be highly transferrable to other rural jurisdictions facing similar healthcare challenges.

Implications for practice

This paper constitutes a first step in the knowledge mobilization process for the warning signs intervention. The next step is to develop an implementation strategy, beginning with the adaptation of the intervention to fit the needs and resources available in rural contexts. While we are conscious that some of the categories of barriers and facilitators are more actionable than others, we suggest that categories identified by all three HCP strata be prioritized for intervention adaptation before incorporating the warning signs intervention into rural TC. The implementation plan should be guided by an evidence-based, ecological framework that emphasizes the importance of local context [64]. Regarding resources, the findings suggest that HCPs could benefit from standardized educational warning signs materials for different health conditions that account for hospital readmissions. Some teaching materials are available (e.g., Congestive Heart Failure) [65] and these need to be identified, evaluated for their evidence, and mobilized into practice. Where teaching materials are unavailable, these need to be developed. HCPs could also seek out training on the warning signs of conditions that they most frequently confront in their practice.

Regarding context of rural practice, telephone follow-up may be a viable alternative to home or out-patient follow-up, as other research has identified that telehealth is feasible in rural health care [66]. Telephone follow-up has also been found to be effective in reducing hospital readmissions [9,67] and has been successfully implemented by hospital nurses serving rural communities [60], highlighting its potential for wider scalability.

Given that rural dwellers expect to be prepared to detect and respond to signs of worsening health conditions because of their limited access to HCPs and the distance they are required to travel to hospitals [12,13], attention to addressing barriers to implementing the warning signs intervention in practice is urgently required.

Implications for policy

One impetus for this study was healthcare administrators’ acknowledgement that HCPs, other than nurses and physicians, may be expected to deliver the warning signs intervention due to the dearth of human health resources in rural communities. Although we recognize that all allied HCPs may not be able to deliver the warning signs intervention independently, it is important to understand that the intervention is interprofessional and hence, all team members can contribute to its implementation [68]. Allied HCPs could support the implementation of the intervention in numerous ways, such as reviewing with patients the education provided by nurses or physicians. However, it is imperative that administrators ensure adequate staffing if they plan to implement a new role for allied HCPs in providing the warning signs intervention to give allied HCPs sufficient time to become competent in this role [69].

Additionally, research indicates that HCPs can learn to deliver new interventions that were not part of their initial training [70]. Members of specialized geriatrics teams, for instance, have been taught to perform geriatric assessments that were not previously part of their job responsibilities [70]. Accordingly, administrators may create cross-professional training opportunities on the provisioning of the warning signs intervention. Such interprofessional approaches are particularly important for rural healthcare provision given the already limited human health resources [71].

Lastly, policy-makers can use our findings to reallocate HCPs’ non-clinical tasks to administrative personnel and to prioritize inter-sectoral communication by linking community and hospital EMRs. Furthermore, such linked EMRs would allow not only for better inter-sectoral communication, but also for performance measurement to foster improvement in real time [72].

Implications for future research

Studies with larger sample sizes of physicians are warranted, as are studies exploring ethical considerations related to physician compensation. Future research is also needed to explore the perspectives of the different professionals that comprise the allied HCP strata. Because studies on the effectiveness of warning signs interventions in rural communities have been limited, effectiveness studies are needed as are studies evaluating the effectiveness and feasibility of participants’ suggestions to improve their ability to deliver the intervention considered in this study. Research is needed on how allied HCPs can support the implementation of the warning signs intervention. Lastly, future research may explicitly sample HCPs from different types of rural communities (e.g., urban adjacent, rural agricultural, rural recreational/cottage county, remote rural) to validate our findings across the full range of rural health care service settings.

Acknowledgments

We thank our HCP participants for sharing their perspectives with us. We also thank Dr. Alex Peel and our other knowledge-users for supporting the study and facilitating recruitment. We also thank Shannon Gordon and Igor Kabanov for their assistance in conducting the literature review for this paper.