# Opportunities for optimising care transitions of adults with multiple long-term conditions: a qualitative interview study

## TL;DR

This study explores challenges in managing care transitions for adults with multiple long-term conditions and suggests system-level improvements to enhance safety and quality.

## Contribution

The study identifies system-level barriers and proposes improvement opportunities using system engineering and stakeholder engagement.

## Key findings

- Care transitions for patients with multiple long-term conditions lack person-centredness and consistency.
- Ineffective communication and integration between services are major barriers to managing care transitions.
- Workforce shortages and knowledge gaps hinder effective care transitions for patients with multiple conditions.

## Abstract

The number of adults with multiple long-term conditions (MLTC) who experience frequent care transitions is rising. Improving care transitions for adults MLTC is important because transitions between and within care settings commonly lead to preventable adverse events. We explored multidisciplinary professional perspectives and experiences of managing care transitions for patients with MLTC to identify opportunities for improvement.

Qualitative interviews with 30 health and social care professionals in four Scottish integrated Health and Social Care Partnerships. Data were collected between May 2023 and March 2024. Thematic analysis was used, guided by the Sustainable Integrated Chronic Care Models for Multimorbidity: Delivery, Financing, and Performance (SELFIE) framework.

Care transitions were described as lacking person-centredness and consistency. Variability in decisions on cross-boundary acute care pathways was largely attributed to human factors (e.g., ease of arranging referrals, a lack of trust or awareness of Hospital at Home service) by hospital specialist staff, but to clinical complexity and home environment limitations (physical and social) by community staff. Ineffective interprofessional relationships and poor communication across services were common experiences, significantly driven by a lack of integration between IT systems affecting timely access to information and by services having different priorities and pressures. Workforce shortages, knowledge gaps in managing MLTC, and long-standing capacity issues in social care were identified as important barriers to effectively managing transitions.

We identified multiple system-level barriers to providing high-quality and safe care transitions. We proposed key improvement opportunities, highlighting the need for using system engineering and systems thinking approaches, underpinned by the active engagement of patients, carers, professionals, and wider stakeholders to drive meaningful and sustainable change in transitions of care.

The online version contains supplementary material available at 10.1186/s12877-025-06264-2.