Utilizing CFIR for improvement and implementation of transitional care management in a rural, academic healthcare system

From the 2021 HVPAA National Conference

John Morrissey (Tuck School of Business, Dartmouth College; Geisel School of Medicine, Dartmouth College), Henry Fang (The Dartmouth Institute, Dartmouth College; Section of General Internal Medicine, Dartmouth-Hitchcock Medical Center), Christina Tsai, Marshall Ward, Ashley Takahashi, Stephen Liu


The discharge process, time to follow-up, and transitional care management for hospitalized patients is wrought with challenges. Given the reduced resources, these challenges are exacerbated in rural settings.¹ Incorporating innovative strategies tailored to serve the needs of the target population are important in creating an effective transitional care delivery system for patients in the rural setting. The Consolidated Framework for Implementation Research (CFIR) has been applied previously to multiple clinical implementation scenarios with improved outcomes.² Herein, we describe the process by which we set out to improve the transitional care delivery system at our facility, using the CFIR framework, by initially engaging in conversation with our staff members and patients. We were able to implement ideas from the published literature into our improvement initiative and develop future steps to create a more robust transitional care system.

A review of an internal database showed the readmission rate, defined as readmission within 30 days of discharge, was as high as 25% for hospital medicine patients in FY2019. High readmission rates are financially costly to the hospital as they increase utilization of inpatient services and reimbursement penalties. The existing transitional care management process for hospital medicine had many gaps in care, primarily in the areas of triaging patients to appropriate follow-up appointment times after discharge, communication between our inpatient and outpatient teams, and inefficiencies in workflow. To reduce readmissions, multiple aspects had to be changed.


To apply CFIR towards challenges in transitional care at our facility and organize implementation steps towards improvement.


The CFIR framework is used to facilitate design, evaluation, and implementation of evidence-based interventions. An abbreviated version of the CFIR framework was used to direct our approach to improve our transitional care delivery system. We conducted telephone surveys and interviews with discharged patients to understand positive aspects of the current system as well as aspects that needed improvement. Similar engagement and group meetings were conducted with staff to understand current processes and gaps in care delivery in transitional care management. Recognizing that triaging patients would be important due to a resource limited number of post-discharge clinical appointments due to availability, we conducted inferential statistics based on clinical variables to assess the best method for predicting hospital readmission after discharge.


Through interviews conducted with patients and care providers, we found the following challenges, barriers, and facilitators (themes that care staff and patients voiced as positives for changes in transitional care) through our conversations. A new process map was created to improve care coordination and clearly delineate responsibilities between the inpatient and outpatient teams. Meetings involving key stakeholders were scheduled at regular intervals with the purpose of improving transitional care delivery. This also served to open lanes of communication among inpatient and outpatient care teams, which previously were not apparent. We internally validated a risk score based on inferential statistics for readmission and the risk score is being implemented into our discharge process.


The CFIR framework helped organize the potential challenges our initiative may encounter when improving our transitional care delivery system. The internal and external interviews, surveys and meetings conducted allowed for greater understanding of gaps in care and improved coordination between teams. We are optimistic that our internally validated risk score will more specifically direct the patients at the highest risk of readmission toward the TCC.

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