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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    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

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.