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The transition period from preparing to leave the hospital (being discharged) to the first few weeks at home can be risky, particularly for older patients.

Most research on hospital discharge has looked at when things turn out badly: a patient has to go back to hospital or has their safety compromised. The authors of this study wanted instead to look at best practice. How do high-performing general practice and hospital teams ensure older patients are safely supported during the transition from hospital to home?

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. These factors were challenging to achieve and were typically only in place when supporting the most complex transitions.

The findings suggest it is valuable for healthcare teams to take time to get to know their older patients and collaborate with other professionals responsible for their care. Structural and systemic changes may also improve safety at transitions.

What’s the issue?

Going home after a hospital stay can be difficult for patients, particularly older people who might find it hard to settle back into daily life. For example, they may not understand their medicines or how to care for their wound. They may have lost the confidence to move about in their homes because they were not physically active in hospital.

An emphasis on shorter hospital stays means that patients may need ongoing care at home. One in five patients experience a problem once they are home and some have to go back to hospital. In the UK, hospital readmission rates have risen by 23% since 2012-13. One in three readmissions is considered avoidable.

A successful discharge means a patient being ready to leave hospital and able to safely manage their condition at home. Most previous research on the transition between hospital and home has focused on what is likely to go wrong. Researchers at the Bradford Institute for Health Research instead wanted to focus on what factors are needed for this process to go right.

What’s new?

Researchers identified six GP practices and four hospital departments in the north of England with low readmission rates for patients over 75. They identified the community nursing teams that worked in or with these high performing teams.

157 healthcare staff from these settings were asked what they felt was important in ensuring patients left hospital safely and did not need to return. Researchers identified themes in their responses that increased the chances of a successful hospital discharge.

The three themes were:

  • Knowing the patient: having a good understanding of the person’s needs beyond their medical condition such as their mental health, living circumstances and worries about managing at home.
  • Knowing each other: having good working relationships within and across the teams responsible for the person’s care. Staff feeling trusted, valued and listened to. Healthcare staff such as physiotherapists and community nurses each contribute an important part of the best plan for the patient. Spending time meeting with colleagues in different teams is key to developing relationships, sharing knowledge about patients and delivering safe effective care.
  • Bridging gaps in the system: with staff trying to overcome the challenges that arise within an imperfect system, and adapting to competing priorities. Staff and patients having all the information they need; staff adjusting patients’ expectations about the care they will receive.

Transitions from hospital to home were likely to be safest when all three themes were in place. However, most staff found achieving all three challenging and only attempted to go above and beyond when the patient had a particularly complex health condition. The researchers suggest that where the three themes are established, a wider range of patients may benefit from a safer transition from hospital to home.

Based on their findings, the researchers recommend:

  • Planning hospital staff rotas to ensure the patient sees the same healthcare professional each time whenever possible
  • Encouraging informal conversations between staff and patients – so trust develops and patients feel comfortable talking about their home situation and any worries they have about discharge
  • Encouraging informal communication within and across teams so that in-depth, nuanced knowledge about patients is shared
  • Training staff such as GP receptionists to sensitively enquire about patients they know and be aware when things aren’t right
  • Bringing staff in different teams together (even virtually) for short educational sessions to help them understand each other’s roles and the pressures and constraints they face. This could include job swaps
  • Creating mechanisms for staff to provide feedback and learning across settings about what could be improved during hospital discharge processes
  • Encouraging an active role for patients and their family during hospital care. Small actions – for example, asking patients to pour water for themselves, get themselves up and dressed, change their own dressing – challenge perceptions about the role of patients and nurses, and prepare patients for managing at home.

Why is this important?

It can be a shock for people to go from being cared for in a hospital to caring for themselves at home. The existing policy on patients leaving hospital focuses on providing support once the person is home. However, this study suggests this support could be too late; patients need to be better prepared for going home in the first place.

What’s next?

This research has led to an intervention that aims to help older patients and their families prepare for going home from hospital and identify any gaps in their care.

Researchers have designed an approach called ‘Your Care Needs You!’ which includes a patient booklet and a short film. This intervention will be trialled in hospital trusts across the north of England to see if it reduces hospital readmissions and improves the quality and safety of the transition from hospital to home for older people.

You may be interested to read

The full paper: Baxter R, and others. Delivering exceptionally safe transitions of care to older people: a qualitative study of multidisciplinary staff perspectives. BMC Health Services Research. 2020;20:780

A guide for clinical commissioning groups and hospital trusts on the safe transition intervention developed following this research: How to promote safety during transitions of care: A guide for CCGs and NHS Hospital Trusts, 2020

Previous research that showed the value of studying positive examples of care: Baxter R, and others. A qualitative positive deviance study to explore exceptionally safe care on medical wards for older people. BMJ Quality and Safety. 2019;28:618–626

The Department of Health and Social Care guidance on discharge:  Hospital discharge service: policy and operating model. 2020

The Yorkshire Quality and Safety Research (YQSR) group website: Partners at Care Transitions (PACT), which provides an overview of their work


Funding: This research is funded by the NIHR Grants for Applied Health Research, Partners at Care Transitions (PACT).

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

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Study author

What makes a difference is not technology or guidelines but relationships. What really struck me was how important trust is, not only between the patient and healthcare professional but across healthcare teams.

Unqualified staff, such as receptionists and healthcare assistants, can also play a vital role because they get to know patients and so can feedback useful information to doctors. For instance, we saw that transitions from hospital to home were more likely to be perceived as successful by healthcare teams that went above and beyond to ensure the patient and their family had extra information about their condition, medication and who to follow up with if they had concerns.

Rebecca Lawton, Professor of Psychology of Healthcare, University of Leeds

Member of the public

I think the focus on what goes right is useful and positive. The research provides actual evidence of what might be seen as common sense.

It is clear however that major barriers to this excellent practice are the time and resources allowed for people within teams to work in this way. Unless the government, commissioners and senior managers really understand and buy into the good practice and make those resources available, staff will continue to be limited as to what they can practically do.

Sandra Barker, Public contributor, Gainsborough, Lincolnshire

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