Objectives: The highly differentiated and specialized healthcare systems are not optimally designed to provide patients with chronic conditions in need of treatment from multi-professional teams with a smooth and seamless care trajectory. Care transitions, especially hospital discharge, tend to be critical for patients' safety and health outcomes. Interprofessional team collaboration across care providers is crucial for efficient and safe care transitions, depending on dynamic and adaptive teams in the unavoidable uncertainty characterizing today's healthcare systems. 

This study explores adaptation and maladaptations in horizontal team collaboration in care transitions of vulnerable patients with complex care needs at discharge from hospital to their private homes.

Methods: The study was conducted in a southern region in Sweden using an ethnographic methodology with participatory observations, document review and interviews. A total of 77 professionals from hospital and primary care participated. A purposive sampling strategy was utilized to capture the interprofessional team collaboration across organizations in the patient's care transition from hospital to home. The comprehensive data was then applied to two patient cases and analysed with the Functional Resonance Analysis Method.

Results: Successful team adaptations as well as maladaptations are revealed as homecare team and patients attempt to manage the uncontrolled conditions in the home after discharge. Maladaptations occur as the organizational capacity is insufficient to meet the needs of the patients in their home environment. The demands challenge the resources of the patient, his or her family, and the homecare team must anticipate and adapt to the unexpected to maintain patient safety. Whether the team adaptations of preparing discharge were successful or not will be revealed through adaptive outcomes or adverse events. 

Information sharing emerges as a central prerequisite for successful team collaboration in care transitions. Flawed or insufficient access to information affected the team performance by hindering anticipating and planning for the care at home. In exacerbations of the chronic illness, information access and communication are needed to obtain a holistic view and respond to the altered care needs. For the team to adapt to the new demands, each team member require a clear understanding of their own as well as other team member’s roles and responsibilities. Ambiguity or imprecision could lead to uncertainty of who does what and where lines are drawn between organizations. 

By interprofessional collaboration during the discharge planning, a shared understanding of treatment and care needed at home is distributed to the team as a collective cognitive mind. Through a shared mental model, the team may anticipate and prepare for the patient's arrival home. When the team collaboration failed or communication was insufficient, gaps appeared, which pressed the need for further adaptations. Successful adaptations could bridge the gaps, maintaining safe and secure care for the patient, while maladaptations posed a risk of patient harm or re-hospitalisation.

Conclusion: To maintain patient safety in transitional care from hospital to home, adaptations to the variability of the system are not to be stifled. Instead, the system needs to allow for flexibility, promoting availability of all resources needed since these are hard to predict. Responding to unexpected events and variations requires allocated resources in the first few days of homecoming, allowing for flexibility and thus increasing patient safety.