Supporting older people transitioning from hospital to home

Key statistics

• the intervention reduced costs by approximately £269 per participant compared with standard care
• a quality-adjusted life year (QALY) gain of 0.0057 was observed over 90 days
• the intervention had an 89% probability of being cost effective relative to standard care.

Key messages

• the ‘Your Care Needs You’ intervention supports older people aged 75 and over during transition from hospital to home
• the cluster randomised controlled trial found lower short-term costs compared with usual care
• small but positive gains in quality of life were observed over a 90-day period
• the intervention is likely to be cost effective in the short term
• the focus is on discharge and transition rather than broader prevention or neighbourhood integration.

Policy implications

• patient-centred discharge support may reduce costs and improve outcomes for older adults
• neighbourhood health and care models could incorporate structured transition support to improve continuity
• integration with community and social care services may enhance impact beyond the immediate post-discharge period
• economic evidence may support commissioning of transitional support interventions.

Gaps

• short follow-up period limits understanding of longer-term outcomes
• limited focus on upstream prevention or neighbourhood-level integration
• social care involvement appears limited within the intervention design
• unclear how benefits vary across different population groups.

Commentary
This study provides robust economic evidence that a structured, patient-centred intervention can improve outcomes and reduce costs for older people transitioning from hospital to home. From a neighbourhood health and care perspective, it highlights the importance of continuity at a critical point of vulnerability.

The findings are particularly relevant for older adults at risk of readmission or deterioration following discharge. Supporting people to manage their care at home may help stabilise health and reduce reliance on acute services in the short term.

However, the intervention focuses primarily on the hospital-to-home transition rather than ongoing neighbourhood support. Without stronger links to community and social care services, opportunities to address wider needs and prevent future crises may be missed.

Overall, the study suggests that transitional care interventions can form a valuable component of neighbourhood health and care, but greater integration with social care and longer-term follow-up are needed to understand their contribution to equity, prevention and sustained wellbeing.