Transition between inpatient hospital settings and community or care home settings for adults with social care needs

Why this is important

There is a lack of UK evidence. There is some evidence from US studies that training improves medical students' confidence in planning hospital discharge. It also shows that dedicated transitions training involving home visits helps medical and pharmacy students appreciate the person's home environment and how it may affect discharge decisions. It does not show whether this translates into improved outcomes or systems.

Comparative studies on staff training are needed to examine which approaches improve outcomes for people and their carers, including safety and safeguarding. They should also examine whether training improves discharge systems and service level outcomes.

Qualitative data are needed from hospital and community practitioners involved in transitions (including managers and frontline practitioners) about their perceptions and experiences of training. Interviews and qualitative studies are needed with people using services and their carers to gauge their views of the skills and competence of practitioners.

The views of commissioners and provider organisations on their experiences of training are needed. A scoping study could identify the range and content of current training and ongoing support for practitioners involved in transitions. The outputs of this could inform future study design.

Why this is important

Current evidence is contradictory and is specific to people with heart conditions. It is not clear whether certain types of transition support is more effective for people with mental health difficulties or more acceptable or preferable from their point of view. Groups with different health or social care needs may need different approaches.

Research is needed on the effect of assessing mental health needs at admission and discharge for different populations. Detailed examination is needed of the components of effective interventions to discover what works, how and for whom.

Data are also needed on the effectiveness of models of multiagency working and how GPs can support transitions from hospital to the community for this population.

Qualitative studies gauging the views of people with mental health difficulties and their experiences of self‑management support during transition could show which components of a self‑management intervention are feasible and acceptable.

Why this is important

The only evidence found was 1 UK randomised controlled trial for frail older people with dementia or delirium. It showed no significant differences in mortality or service outcomes, and did not consider community care resources or unpaid care.

Cost‑effectiveness analyses are needed to determine the cost of assessing this group's needs in hospital and in specialist units, and the cost of health and social care, unpaid care, and the effects on employment and housing.

Determining the cost of assessment while in hospital is particularly important for patients with dementia or delirium because early identification of difficulties might lead to long‑term savings for the public sector and society.

Research is needed on what measures are effective in preventing, managing or resolving dementia or delirium during transfer. Research is also needed on what training is most effective for hospital staff supporting people with mental health difficulties during the transition.

Why this is important

Currently there is no UK evidence in this area.

International evidence (mainly from the US) and evidence from the economic analysis carried out for this guideline suggest that care in a specialist unit is likely to be cost effective. But in England most older people – including those with complex needs – are treated on general wards.

It is important to establish the incremental cost and outcomes of provision by mobile teams working on general wards compared with specialist units. Costs need to include the use of health and social care resources (including in the community and care homes) as well as unpaid care.

Data are needed for costs and outcomes 6 to 12 months after discharge: the time horizon should be sufficient to measure the effects on mortality, hospital readmissions and care home admissions.

Why this is important

Little research has been conducted in this area. There is some evidence that older people find hospitals alienating because of the negative impact on their routine. One Australian qualitative study highlighted the challenge for occupational therapy if it is decontextualised from normal life, but the findings could not be extrapolated to UK practice.

Qualitative studies with people who were assessed at home could inform the design of future interventions, by exploring the feasibility and acceptability of home assessment compared with hospital assessment.

Randomised controlled trials are needed to compare the effectiveness of an assessment in hospital with a home assessment after discharge, from a social care needs perspective for different populations. In addition, information on patient‑ and cost‑related outcomes is also needed.