Implementation Fidelity of the Transitional Care Model: A Mixed Methods Study

Abstract This study, conducted in parallel with the Multisite Replication of the Transitional Care Model, evaluated implementation of the Transitional Care Model protocol delivery (primary aim) and the randomized clinical trial protocol (secondary aim) across nine hospitals and community partners within four healthcare systems. Guided by the Practical, Robust, Implementation, and Sustainability Model and applying a concurrent mixed-methods design, outcomes were assessed using an embedded Reach, Adoption, Implementation, and Maintenance framework, excluding effectiveness. Fidelity to implementation was measured as a standardized count of protocol components delivered as intended (range 0–38). A mean fidelity score of 34 demonstrated that approximately 90% of the minimum dose was delivered, with fidelity improving over time from year 1 (mean 32) to year 3 (mean 35). Qualitative content analysis of 210 meetings identified 24 challenges and 15 strategies related to TCM delivery. Common challenges included engaging patients and caregivers, decreased access to post-acute services, complexity of team-based care, and limited nurse availability. Strategies to address these challenges included testing alternative approaches, building and engaging care networks, targeting patient and caregiver engagement, focusing on care coordination, and emphasizing plans of care. COVID-19 substantially disrupted trial implementation, including the withdrawal of one healthcare system, resulting in reduced enrollment (1004 of 1600 planned patient participants) and staffing delays. At trial completion, one system had integrated the Model into routine practice, while others were planning for sustainability. These findings highlight the importance of ongoing systematic assessment of both intervention delivery and trial implementation to contextualize and interpret outcomes.