Strategies to address implementation barriers in sepsis survivors’ care transitions to home health and outpatient care: a multi-site, type 1 hybrid implementation study

BACKGROUND: Timely attention by home health care (HHC) and outpatient providers within one week after hospital discharge is associated with lower readmission rates among sepsis survivors. However, few patients nationwide receive this pattern of care. Improving care transitions for sepsis survivors is inhibited by barriers in sepsis identification, information transfer, care coordination, timely access to care, and patient engagement. The I-TRANSFER study was designed to address these gaps by implementing timely delivery of post-acute care (PAC) for sepsis survivors in real-world health care settings. The study aimed to identify, describe, and map the implementation strategies used to implement the I-TRANSFER care transition protocol. METHODS: Five diverse health systems (16 hospitals), partnered with an affiliated HHC agency, participated in a Type 1 hybrid implementation science study. Through thematic inductive and deductive qualitative analysis, implementation determinants-barriers and facilitators-were identified, summarized, and presented back to the sites' implementation teams. This paper reports on implementation strategies used to address barriers and implement the I-TRANSFER care transition protocol. Strategies are mapped to the Expert Recommendations for Implementing Change (ERIC) taxonomy. RESULTS: Implementors and researchers deployed strategies spanning 62% of the 73 ERIC categories, resulting in hundreds of detailed examples. Strategies aimed at identifying sepsis and referring survivors to HHC emphasized relaying clinical data to providers; adjusting the EHR; and educating staff to improve sepsis recognition, documentation, and referral to HHC. Strategies aimed at information transfer and making outpatient appointments emphasized EHR-based tools, telemedicine workflows, and centralized scheduling to ensure communication to PAC and timely outpatient appointments. Providing timely HHC and outpatient visits required staff and patient education, tailored HHC pathways, patient-focused interventions, and quality monitoring. Cross-cutting strategies reinforced coordination and education across the full continuum of care. Heat maps illustrate which strategies were used most often across objectives and by hospital/HHC dyad. CONCLUSIONS: This study identified, described, and mapped to the ERIC taxonomy more than 450 implementation strategies used by hospital-HHC dyads to implement the I-TRANSFER care transition protocol, providing practical, translatable strategies to support timely post-acute care transitions for sepsis survivors. By identifying the barriers in care transitions, and reporting the strategies to address them, these findings can inform broader efforts to deliver timely, coordinated care and improve outcomes for vulnerable populations across settings.