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Table 4 Comparison of themes from years 1 and 2 of TNP implementation

From: Training registered nurses to conduct pre-implementation assessment to inform program scale-up: an example from the rural Transitions Nurse Program

Year 2 theme

Overlapping year 1 theme(s) [6]

Perception that the program is necessary.

Positive to mixed reaction to the program

Concerns around work duplication.

Concerns about work duplication

There are barriers to effective primary care follow-up.

Transportation challenges

Difficulties recruiting and retaining providers in rural areas

Discharge processes are complex and challenging.

Areas for improvement in current transition of care processes

Impact of the Veteran’s Choice Program

Need for program buy-in.

Concerns about infrastructural support for the program

Difficulties with communication.

Disconnect between primary care teams and hospital inpatient teams

Weak infrastructural support for coordination of care between hospitals and PACT sites

Difficulty contacting patients