Care transitions Other
Conditions
Interventions
Current interventions as of 07/08/2020:
The research will take place within 40 wards (across 8 acute NHS Trusts) over a 12 month period. In total, 20 wards will deliver the intervention and 20 wards w
Sponsors
Bradford Teaching Hospitals NHS Foundation Trust
Eligibility
Sex/Gender
All
Inclusion criteria
Inclusion criteria: 1. Aged 75 and over 2. Anticipated to be discharged to their own home or that of a relative’s (this can include a period of rehabilitation after hospital discharge) 3. Stayed for at least one night on a participating ward 4. Ability to read and understand English or has a carer that can read and understand English 5. Willing and able to give informed consent (or personal consultee if lacking in mental capacity)
Exclusion criteria
Exclusion criteria: Current participant exclusion criteria as of 07/08/2020: 1. Patients who have previously been recruited to the study (e.g. during a different admission or on a different ward) 2. Patients / Consultees who require an interpreter (e.g. because they are unable to read or understand English). 3. Patients who live out of the area included in the study 4. Patients who are expected to be transferred to another acute hospital/trust prior to discharge 5. Admitted for psychiatric reasons (other than dementia/delirium) 6. Nursing/residential home resident or planning to be discharged to a nursing / residential home on a permanent basis 7. Identified as being at the end of their life / subject to fast-track discharge to palliative care 8. Unable to give informed consent and where a suitable personal consultee cannot be identified, or if no one is prepared to act as a consultee for the patient Previous participant exclusion criteria: 1. Out of area patients and/or patients who are to be transferred to another hospital 2. Admitted for psychiatric reasons (other than dementia/delirium) 3. Nursing/residential home resident or planning to be discharged to a nursing/residential home on a permanent basis 4. Less than one overnight stay (on the participating ward) 5. Identified as being at the end of their life/subject to fast-track discharge to palliative care 6. Unable to read and understand English and without a carer who can read and understand English 7. Unable to give informed consent and where a suitable personal consultee cannot be identified, or if no one is prepared to act as a consultee for the patient 8. On an acute medical admission unit and to be transferred to another ward within the hospital
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| 30-day hospital emergency readmissions, measured using routinely collected data on 30 unplanned hospital readmissions | — |
Secondary
| Measure | Time frame |
|---|---|
| 1. Quality and experience of care transition for patients, measured using Partners at Care Transitions Measure (PACT-M) at 7 days, 30 days and 90 days post discharge 2. Difficulties that patients experienced in hospital that could affect them after discharge, measured using Post Hospital Syndrome questionnaire at 7 days post discharge 3. Quality of life, measured using EuroQol 5-Dimension Health Questionnaire (5 levels) (EQ5D-5L) and Proxy EQ5D-5L at 7 days, 30 days and 90 days post discharge 4. Healthcare resource use measured using unvalidated questions about services used since discharge at 7 days, 30 days and 90 days post discharge 5. Utility of the intervention measured using unvalidated questions asking about the intervention at 7 days post discharge 6. Unplanned readmissions at 60 and 90 days, measured using routinely collected data | — |
Countries
United Kingdom
Outcome results
None listed