Multi-disciplinary teams should work across hospital and community settings – including with services provided by community health, adult social care and social care providers – to plan post-discharge care, long-term needs assessments and, where appropriate, end of life care.
Life transitions can be difficult for anyone but the potential for anxiety and disruption is amplified when people with long-term conditions or disabilities are being asked to move from one support setting or service network to another. These service transitions often coincide with a broader change in someone’s overall stage of life such as when a young person with a disability or mental health difficulty moves from children to adult services, or when an older person with dementia moves into a residential care home. Such transitions also affect family carers who will commonly experience considerable changes in their personal circumstances and caring responsibilities. Discharge from hospital is another often stressful transition as someone is moving from an environment in which there is continual access to care, to one in which they will be more reliant on their own abilities and support from their informal carers and networks.
Well-managed transitions of care are those which are sufficiently planned before the day of the move, involve the person and if appropriate family carers in the decision-making, and are coordinated around the interests and needs of the individual.
Explore transitions of care
How do well-managed transitions relate to integrated care?
Despite many previous attempts in national policy and practice guidance to improve the co-ordination of care, we found lots of ongoing examples of disputed responsibilities, delays, hand offs, ‘cost shunting’ and ‘turf wars’.
It is at those times of transition when the need for person-centred and coordinated care is arguably at its greatest. Professionals may not be clear about who is responsible for what in the new setting, communication processes and digital records may not operate beyond existing service boundaries, and different access criteria, modes of care, and service capacity may be in place. Relationships that people have developed with key professionals are likely to be lost which then requires them to retell their personal stories and establish connections with new teams. Basic but key information such as how to contact new teams and when they will visit are not always clearly communicated to the person or their family in advance of their move. Well-managed transitions cannot prevent all of this disruption but can reassure people and their families that there is continuity in their support based on a shared understanding of their care needs and what matters to them as individuals.
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 do transitions of care need in order to succeed?
High level strategic leadership, commitment and coordination are vital. Across the council there will need to be leadership and commitment to a whole family approach, with protocols in place across a wide range of local partnerships to enable services to be coordinated and responsive to the needs of young carers in their transition to adulthood.
Multidisciplinary staff from general practice, hospital and community care teams were interviewed about what they felt was important for a successful transition. The study identified three factors: knowing the patient; knowing staff within and across teams; and bridging gaps in the healthcare system.
Transitions of care involve people moving through the boundaries of existing care provision. By their nature therefore, transitions require systems working in which organisations look beyond their usual responsibilities to connect with other services and collaborate to provide a seamless transfer process. When barriers relate to uncertainties or arguments about who will pay for the new support, it can be helpful for organisations to consider pooling funding into a shared pot for facilitation of the process or needs of a population. This is often deployed when those in a population are likely to have complex needs, such as people who are homeless or who have a profound disability. Senior leaders set the overall vision for how people in the local system will experience transitions and can work to challenge existing practices or rules which prevent new models being implemented.
Professionals responsible for supporting someone during a transition need time and opportunity to communicate with the person and family carers, to understand what is important to them, and identify any anxieties which they may be experiencing. This will enable the professionals to ensure that these issues are addressed thoroughly in the process. Developing good communication and respectful relationships with the teams who will subsequently be responsible for providing care facilitates trust between the services and confidence in raising any concerns in the transition.
What is the evidence for outcomes and impact?
A Transitional Care Model which includes multi-components namely pre-discharge and intensive post discharge follow-up components can reduce hospital readmission and ED visits. Components like shared decision making, involvement of informal caregiver and a small, tailored care team with a defined coordinator can increase the success.
The results are encouraging as they show that discharge programmes can be effective in reducing homelessness and hospitalisations and may be effective in reducing reincarceration post-discharge.
Well-managed transitions can have multiple benefits, dependant on the transition in question. For example, timely and supported discharge from hospital can reduce the likelihood that someone will be readmitted for a similar issue in the short term, and that acute care capacity is not occupied by people who would be better cared for in a community setting. This also reduces the likelihood that someone will experience deterioration in their physical and mental health associated with an in-patient stay or be at risk of a hospital-based infection. For all transitions, people having the opportunity, time, and support to prepare for the change and make decisions over what is important increases the likelihood that their stress and anxiety will be reduced and that their wellbeing will not be adversely affected by the move.