Table 3 Overview of themes

Organization

Work-flows for Screening and Referral as a Facilitator

Physician: “I think one barrier would be consistency. And so while you might be able to get one thing at one practice, is that really the same thing that happens across the system, right? And ensuring that consistency. So that when you as the parent go in, are you filling out the same forms and being asked the same questions that you were when you went with your kid … Having that recall. Oh, they’re supposed to be seen a lot so somebody knows that, not just me, but the front desk knows that, so yes, they will definitely get them in in a month, or...it’s a system wide effort to remember all these little gaps, and you know all the little points that need to be filled in, to meet the quality measure...so managing that process and then making sure the person, or somebody is responsible to do the job.”

Work-flows for Screening and Referral as a Barrier

Director of Nursing: “So our case management team, we have, you know, I suppose, like most facilities have daily rounds where you’re looking at discharge planning and last year one program that we implemented was including our ambulatory care coordinators in the conversation, so that when the patient is discharged from hospital, someone, there’s a warm handoff of information so that somebody is going to be following up.”

Buy-in/Leadership

Care Coordinator: “I feel like [the organization I work for] has given us the opportunities to do a lot of learning, which I think has helped us. My learning in particular has you know, I, I had had, I don’t know now [but], looking forward after COVID and everything what this will look like in the next year or so, but usually I’ll have like a learning budget to attend conferences and things like that. So that’s valued by [my organization].”

Community

Resources

Director of Nursing: “Internet access is somewhat of an issue. Transportation is always [an issue]. No coverage with needed services in rural areas. No long term care beds or memory care beds. A lot of patients without needed insurance for post-acute care needs, including nursing home placement.”

Care Coordinator: “Yes, there are tons of places in the Twin Cities but people that have that typically what I see is that people that have state insurance, do not have reliable transportation. It’s just how it is. And most people are not comfortable riding in a medical taxi, all the way down to the cities with a stranger with their baby. Um, so it’s like yes, there are certain resources available, but are they ideal for a lot of families, no and if there are other children, there is no childcare, I mean, that just you know what I mean it just snowballs and all these other like other barriers, essentially, but yeah sorry I kind of got off topic there.”

Partnering

Physician: “I talked about the homeless advocate. She has kind of initiated a release of information for lots of agencies in the area including the hospitals, including some of the mental health resources and housing resources. And so there’s a population of, somewhere between 100 and 200 people who have signed one of those. So if somebody has one of those signed, I feel a little bit more comfortable calling different folks and kind of connecting.”

Case Manager: “There just isn’t a point person at [the] public health [department] that can help be that navigator and have that continuity with, with the organization and the community.”

External/State

Payer Policies

Administrator: “If we’re going to really drive the program well we need dedicated resources which cost money, and there’s not a really a clear financial return yet and we see we’re doing the right thing for the community but we’re paying money to keep people out of the facility which is also having an impact financially so the methodology for reimbursement in healthcare is not exactly aligned for prevention and public health and improvement in overall wellness so that’s challenging.”

Care Coordinator: “So [a] TCM call is basically transitional care management - so any individual who’s discharged from a hospital setting, we follow up on from a care coordination standpoint, offering support, ensuring that, you know if they had orders for home care that they are set up and in place. Basically, our goal is to ensure that when they’re at home, they’re successful and don’t end up back in our [emergency room] or hospitalized for the same purpose and so offering to reconcile the medications, and just reviewing what their home life is like and any challenges [or] barriers, things along those lines that might play a role in a potential readmission.”

Misaligned Incentives

Collaborative Staff: “Quality measures superficial – especially at hospital level – was meal nice, room, etc. Need to pay attention to quality measures to capture SDOH. Did the care coordinator help you get housing and transportation? Lots of work goes into that, but not measured currently.”