Transitions of care
What are well-managed transitions of care, and why are they important?
Timely and safe transitions of care ensure people receive the support they require in the right place and at the right time, moving swiftly and seamlessly through services and settings as their needs change. Well-managed transitions between care settings provide continuity of care, such as at discharge from hospital to home.
Poorly managed transitions result in people experiencing fragmented care and unmet needs as they journey through the health and care system. The interface between hospital care and community services following hospital discharge is of particular concern. Poorly managed transitions contribute to delayed transfers of care, adding pressures to acute services, and they may highlight inadequate capacity in community services, inaccessible social care packages or poor communication between care providers.
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Video transcript Open
What are well-managed transitions of care? And why are they important?
Timely and safe transitions of care ensure people receive the support they require in the right place and at the right time. People move swiftly and seamlessly through services and settings as their needs change. They enjoy continuity of care such as at discharge from hospital to home or from community health services or social care.
While with poorly managed transitions people can experience fragmented care and unmet needs as they journey through the health system.
Who benefits from well-managed transitions?
Older and frail people, people with long-term and complex needs and people with mental health problems all benefit from well-managed transitions. But it also benefits those who may simply need some short-term support in the community to im-prove their independence.
What steps are needed for successful transitions?
There are some key interventions that support delivering good transitions. It's important to think about transitions across the whole health and care system and not only post-hospital care, although that has been the main focus.
Effective interventions include:
- single point of access for managing urgent care
- multidisciplinary discharge teams
- trusted assessors
- Red Bag schemes.
The success of these approaches is dependent on factors such as clear leadership, communication between staff and support in the community such as housing services. Having adequate resources and a culture of data sharing are vital.
What is the evidence for outcomes and impact?
As well as fewer delayed transfers the timely provision of the right care and the right settings results in a better experience for the patient, reduction in costlier hospital care and many other benefits.
Timely and safe transitions result through good working relationships between health care, social care, housing support and the voluntary sector. Better for the team, better for the community and better for the individual.
Explore transitions of care
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Guidance Open
- Transfers of care: signposting resource
- Promoting independence through intermediate care (SCIE 2018)
- Quick guide: hospital transfer pathway 'Red Bag' (NHSE 2018)
- The transition of older people from their own residence to a care home (RCN 2018)
- Admissions to residential and nursing care from hospital and delayed transfers of care (ADASS, 2018)
- Guide to reducing long hospital stays (NHS Improvement 2018)
- High impact change model (LGA et al. 2017)
- Understanding intermediate care, including reablement (SCIE 2017)
- Developing trusted assessment schemes: 'essential elements' (NHS Improvement 2017)
- Rapid improvement guide to trusted assessors (NHS Improvement 2017)
- Moving between hospital and home, including care homes (NICE & SCIE 2017)
- Intermediate care including reablement: NG74 (NICE 2017)
- Quick guide: discharge to assess (NHSE et al. 2016)
- Transition between inpatient mental health settings and community and care home settings: NG53 (NICE 2016)
- Transition between inpatient hospital settings and community or care home settings for adults with social care needs: NG27 (NICE 2015)
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Practice examples Open
- Acting without delay: how the independent sector is working with the NHS to reduce delayed discharge (NHS Cofederation 2017)
- High impact change model: managing transfers of care (LGA 2017)
- The role of housing in effective hospital discharge (Skills for Care & CHI 2017)
- Housing: getting people home from hospital (Housing LIN)
- Cornwall Hospital Discharge Partnership Project (Housing LIN 2017)
- Enabling early discharge (Monitor 2015)
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Measuring success Open
- P3C measures for transitions & continuity (Plymouth University)
- NHS-Social Care Interface Dashboard (DHSC 2018)
- High impact change model (LGA et al. 2017)
- Local authority area data profiles (CQC)
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Research Open
- Beyond barriers: how older people move between health and social care in England (CQC 2018)
- Impact and experiences of delayed discharge: A mixed- studies systematic review (Health Expectations 2018)
- What works in delivering effective hospital discharge services? (Cordis Bright 2018)
- Managing the hospital and social care interface: interventions targeting older adults (Nuffield Trust 2018)
- Does integrated care reduce hospital activity for patients with chronic diseases? (BMJ Open 2016)
- Going home alone: counting the cost to older people and the NHS (Royal Voluntary Service 2014)
- Organisational interventions to reduce length of stay in hospital: a rapid evidence assessment (Health Services and Delivery Research 2014)
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Latest evidence Open
These are the latest resources from Social Care Online, the UK’s largest database of care knowledge and research.
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Transforming care: how can progress be improved?
- Association of Directors of Adult Social Services, 2020 -
Hospital discharge service: policy and operating model
- Great Britain. Department of Health and Social Care, 2020 -
Harnessing housing support: Nottingham Housing to Health service: review of project enablers and potential for spread
- Alice Jones Impact Consulting, 2020 -
590 people’s stories of leaving hospital during COVID-19
- Healthwatch England, 2020 -
Hospital discharge service requirements
- Great Britain. Department of Health and Social Care, 2020 -
Evaluation of an early discharge from hospital scheme focussing on patients’ housing needs: the ASSIST Project
- Wiley, 2020 -
Hospital referral for assessment for community care and support: implementation guidance
- Professional Record Standards Body, 2020 -
Readying the NHS and adult social care in England for COVID-19
- National Audit Office, 2020 -
Perspectives of older adults regarding barriers and enablers to engaging in fall prevention activities after hospital discharge
- Wiley, 2020 -
ADASS coronavirus survey
- Association of Directors of Adult Social Services, 2020
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Transforming care: how can progress be improved?
How do well-managed transitions support integrated care?
Timely and safe transitions are the culmination of complex care coordination processes and interdependencies between sectors and settings, including health care, social care, housing support and the voluntary sector.
An effective and smooth transition is a prime example of integrated care in action because it depends on the contributions of multiple services and the collaboration of professionals across organisational boundaries.
Who benefits from well-managed transitions?
Interventions that support timely and safe transitions are generally aimed at ensuring people can find adequate support when they no longer require hospital care, either from community health services or social care. This includes older and frail people, people with long-term and complex needs and people with mental health problems, but also those who may need additional short-term support in the community to improve their independence.
What steps are needed for successful transitions?
Several approaches and interventions can support effective delivery of a good transition of care. These include:
- early discharge planning
- multidisciplinary discharge teams
- co-located / embedded housing support (within discharge teams) and community-based practical housing support
- trusted assessors
- Red Bag schemes
- discharge to assess schemes
- intermediate care interventions that facilitate transition including step-up and step-down care and reablement services.
The effectiveness and success of these approaches is dependent on factors such as:
- a culture of collaboration amongst care professionals and across organisations, supported by clear leadership
- vertical integration bringing acute and community services together, setting a precedent for other types of integration
- a good offer of services and support in the community, including partnering with housing services
- sharing learning between staff, and discharge teams and clinicians being located in the same place
- having the autonomy and resources to innovate and improve services
- information and data sharing across services and agencies.
What is the evidence for outcomes and impact?
Fewer delayed transfers of care is not the only measure of effective approaches to transition of care. The timely provision of the right care in the right settings results in:
- better experience of care for patients
- reduced risk of physical and mental decline in older people associated with spending extra days in hospital
- reduced risk of catching hospital-acquired infections
- shifting demand from costlier hospital care to community-based services
- freeing acute care capacity and beds for severely ill patients.