Background

Navigating care transitions for patients with complex care needs represent a formidable challenge, where resilience becomes a crucial benchmark for quality and safety. There is a need to develop a healthcare infrastructure that not only reacts to disruptions but also proactively strengthens its capacity for continuity and patient safety. By addressing vulnerabilities and enhancing systemic responsiveness, the study illustrates how a coordinated, patient-centered approach is pivotal in building a healthcare infrastructure that can effectively navigate and adapt to challenges, thereby embodying the essence of resilient healthcare.

Objective

The aim of the study was to visualize vulnerabilities inherent in care transitions and to demonstrate how resilience—manifested through interprofessional collaboration and organizational adaptability—can fortify these critical junctures for patients with complex care needs.

Methods

Employing an ethnographic methodology, we engaged in document review, participant observations, and interviews with an array of healthcare and social care professionals involved in the care trajectory of patients with complex care needs. Narrative analysis was employed to construct two illustrative patient scenarios, which were then examined using the Functional Resonance Analysis Method (FRAM). Thematic analysis was subsequently applied to synthesize the findings.

Results

Our findings reveal that timing and precision variability during care transitions not only exacerbate vulnerabilities but also jeopardize patient safety. The inherent systemic rigidity, particularly during non-standard hours, amplifies the strain on resources and escalates the demands placed on care providers. In the face of patient needs' inherent unpredictability, the capacity of an organization to adapt is not just advantageous but essential. The crux of resilience in this context is interprofessional collaboration, which empowers healthcare teams to manage care proactively and navigate transitions more securely. Through collaborative practices, professionals are equipped to pool knowledge, predict fluctuations in patient conditions, and proactively coordinate responses to unexpected situations.

Conclusions

We advocate for a resilient model of care transition that is anchored in the collaborative synergy of healthcare teams, strategic resource management, and robust communication infrastructures. This model advocates for the vital contributions of frontline workers, patients, and their families, suggesting that their involvement is key in overcoming systemic obstacles and championing integrated, person-centered care. Our proposed pathway seeks to foster a healthcare environment where resilience is ingrained in the culture and practices, thereby ensuring safe, continuous, and responsive care transitions for all patients, particularly those with complex care needs.