Translating evidence into best practice

In a project undertaken in metropolitan South Australia, we identified older people living at home who presented at one of the major acute hospitals four or more times in one year and invited them to take part in focus group meetings to understand the problem from their perspective. We also invited staff from the hospital, from primary care and aged care to take part in similar focus group discussions. We then held a meeting with older people and service providers together so that they could hear each other’s point of view. From the older person’s perspective, an important point they raised was that when they went home from hospital, their social needs were a priority, not just their clinical care. For both older people and service providers, gaps in communication and information provision between the older person and their family, the hospital, general practitioners, aged care providers were identified. This led to the idea for a project titled ‘Something Missing in the Middle’ to develop and test a solution to reduce unnecessary hospital presentations for older people.

Creating a solution to a problem involves working together to explore approaches that could work in the local setting. In ‘Something Missing in the Middle’, this involved co-design workshops with older people and service providers to build on the issues identified from the initial focus group meetings. These meetings had helped to really clarify what the problems were. The next step was to identify a possible solution to the problems. At this point, we reviewed the evidence to see what approaches had already been tried and tested. This did not provide us with a ready-made solution, but it did highlight the importance of developing a person-centred, locally relevant solution. Existing evidence also identified key principles that were important to consider, for example, targeting individuals most at risk, coordinating care and communication between different services, helping to navigate transitions in care and actively involving older people and their carers. This evidence was discussed in the co-design workshops and the decision was made to focus on a care transition service supporting older people being discharged from hospital to home.

From the earlier exploration of the problem, we knew that to improve the older person’s experience of leaving hospital to return home, a care transition service would need to support both their clinical and non-clinical needs. For example, older people had shared their experiences of returning home to an empty house and not having any food in the fridge or not being able to get to the pharmacy to collect their medicine or to a follow up appointment with their General Practitioner. Taking these issues into consideration, older people and service providers co-designed a Care Transition Service that would be provided by a clinical nurse and an allied health assistant. These two roles would work together to support older people identified at high risk of hospital re-presentation for six weeks following hospital discharge.

Having designed a solution, the next step was to implement and evaluate the Care Transition Service in a 6-month pilot study. In the next KnowledgeConnect, we will describe what was involved in implementing and evaluating the new service, including the challenges encountered, how we addressed them and how well the new service worked.

The next step involved synthesising the co-design findings with relevant research to develop an improvement intervention that could be implemented and evaluated in a real-world setting. The research evidence did not provide a ready-made solution but highlighted the importance of the transition process from hospital to home. This included identifying and supporting older people at the highest risk of hospital re-presentation, for example, by actively coordinating their care and helping to navigate the transition from hospital to home. The evidence also indicated that a previous unplanned hospital admission in the preceding six months was a key risk factor for future unplanned hospital presentations.

We then reviewed the findings from the final co-design workshop where older people and service providers worked together to propose potential solutions to the problem of ‘Something Missing in the Middle’. The identified solution centred around creating a new role to fill the gaps in care and provide functional and emotional support to the older person, which would help to increase their confidence on returning home from hospital. It was viewed essential that this was a role that was flexible and had autonomy to support, educate and advocate for older people both in hospital and in the community and to coordinate and communicate with all stakeholders involved in the person’s care. This aligned with the research evidence on the importance of care navigation and managing the transition process. Hence the decision was made to pilot a Care Transition Coordinator role within the geriatrics service of a local health network.

The outcome of the co-design workshops with older people and care providers was a decision to pilot a Care Transition Coordinator role within the geriatrics service of a local health network. The next steps involved working with the geriatrics team, some of whom had participated in the co-design workshops, to establish the role of Care Transition Coordinator. The geriatrics service already had a team that provided services in the community, with a particular focus on post-discharge clinical follow up, typically for a time-limited period. In discussion it also became clear that one thing that was lacking in the existing service was a care assistant role. This meant that the clinical nurses sometimes had to provide the social support that was missing for older people, for example, if there was no food in the house when the community nurse visited post-discharge. These two issues of support over a longer transition period and the need for social as well as clinical support informed the final design of the new service. Rather than focusing on a single role, the decision was made to combine a clinical nurse with an allied health assistant, thus creating a Care Transition Coordination Service. This meant that some trade-offs had to be made within the overall budget available and two part-time roles were advertised, rather than a full-time clinical nurse. The rostering was arranged so there was also one day where both the nurse and the allied health assistant worked together to enable effective communication and handover. Other practicalities to be considered including things like access to a car to make home visits to older people and provision of a mobile phone.

In relation to delivering the service and drawing on evidence from previous studies of care transition, it was agreed that the follow up period after discharge should be up to 6 weeks. Eligibility criteria for older people who could access the service were also specified and communicated to teams within the Emergency Department and relevant wards within the hospital. These included that the older people had to be an unplanned presentation at the hospital, aged 75 or older, and living at home. The clinical nurse recruited to be part of the new service communicated with colleagues within the hospital to raise awareness of the service and encourage referrals. A range of data were then collected by the research team to assess the feasibility, acceptability, and experience of the Care Transition Coordination Service from the perspective of older people, their family carers, clinical staff referring into the service and the two staff in the clinical nurse and allied health assistant roles. The findings from the evaluation will be presented in the final part of this KT Connect case study.