The 6 A’s Global Transitional Care Model for Addressing Hospital-to-home Care Fragmentation

Introduction: An acute illness or injury can be life altering. However, few systems of care are organized to support individuals in the transition home from the acute hospital. Fragmented transitions in care lead to preventable complications, disability and depression. Care transitions without adequate planning and follow-up after an acute illness or injury is increasing the global disease burden. Methods: Our aim was to design a transitional care model appropriate for both developed and developing countries. We conducted a mixed methods study guided by the socioecological model that has a theory-base for understanding interacting levels of influence societal, community, institutions, social, family on individual behaviors and outcomes. We synthesized peer-reviewed and grey literature to identify national and regional infrastructure, health care and community-based strategies, involvement of family, and meaningful patient outcomes examined in transitional care models with demonstrated effectiveness. Our policy analysis for twelve countries three low-, middle- and high-income examined healthcare finance, availability and access to services, payment or policies for caregiver leave of absence, and products and technology that support independent living. Eighteen key informant interviews with healthcare and community leaders in six countries were conducted to assess the knowledge, attitudes and practices regarding hospital-to-home care transitions. Results: Key informants in each low-, middle- and high-income country acknowledged the challenges with fragmentation and opportunities to improve care coordination. Although fewer supportive policies were legislated in developing countries, several national strategic plans acknowledged key areas for development such as improving access to care or health information technology. These perspectives, policies and the evidence-to-date led to the development of the 6 A’s global transitional care model to address the fragmentation in care and improve outcomes. The essential components of the 6 A’s model are to assess, advise and educate patients and families, arrange follow-up, services and supports, access and attend organized follow-up, adopt self-management strategies and positive behaviors, and achieve the greatest quality of life measured outcomes. Discussions: The 6 A’s model was designed to be implemented in the hospital assess, advise, arrange and after hospital discharge in the community attend, adopt, achieve and the components are balanced for accountability between healthcare providers, patients and families. While each setting may present with unique challenges for implementation, our formative research indicates that local creative solutions are possible once the need and buy-in are established. Conclusions: The 6 A’s model is largely dependent on care redesign or re-alignment of existing resources and skills training. Local policies and perspectives will need to be considered for each implementing environment. Lessons: Scale-up of transitional care models tested in high-income countries to lower resourced areas will not be feasible. The 6 A’s holds promise as a global model that can be considered within local contexts. Limitations: Although our research engaged representatives and included literature from a diverse selection of countries, key informants were advocates for improving integrated person-centred care. Future research: Implementation research using a community-based participatory approach with attention to the six health system building blocks is recommended for the 6 A’s global transitional care model.