Let's all get home safely: a commentary on NICE and SCIE guidelines (NG27) transition between inpatient hospital settings and community or care home settings

Abstract

Safe and appropriate transition between inpatient settings and the community is one of the major challenges facing the modern NHS. The National Institute for Health and Care Excellence in conjunction with the Social Care Institute for Excellence published guidance on this challenging area in December 2015. This commentary provides context, summary and discussion of the key areas covered. The guidance particularly emphasises the importance of a person-centred approach in which patients are individuals and equal partners in the multidisciplinary team who should be treated with dignity and respect. Additionally, communication and information sharing is crucial both on admission and when taking a proactive approach to discharge, including the role of the discharge coordinator in liaising with community teams and arranging follow-up post-discharge. Self-care and the significance of carers are also highlighted as valuable in facilitating safe discharge and reducing readmissions. It is clear that in older people with complex needs, safe appropriate transition between hospital and community settings has a positive impact on patients and their carers. Given the financial and capacity pressures facing the NHS, strategies to reduce readmissions and prevent delays in discharge are increasingly important. These guidelines are therefore both timely and advocated to improve care for older people.

Essential information for transition of care for frail elderly patients in Japan: A qualitative study

“…First, our study revealed that the current process of information transfer is suboptimal. Information lacking in the care transition process identified in previous studies includes prior investigations, 23 medication, 24 and adequate attention to assessing comprehensive social conditions, especially among the elderly 25 . Our participants identified similar items, and all agreed that improving information transfer may improve the current care transition process.…”

Multidisciplinary interventions for reducing the avoidable displacement from home of frail older people: a systematic review

“…Some parallels with other broad-based initiatives such as intermediate care can be seen. In the UK where intermediate care concepts have been operationalised, they include four types of intervention: crisis response, home-based care, bed-based care and reablement 32. The category of home-based care in this review corresponds with the hospital at home category.…”

“…This was an important omission which might have been averted through more robust application of the avoidable displacement from home framework. Likewise, including place-based care as an analytical theme would have revealed degrees of service integration and fragmentation, especially for interventions that seek to integrate external care with services at home 32. It was not possible to determine the degree of service integration for most interventions, but the available evidence for the medication review intervention indicated that it did not fully satisfy Kodner and Kyriacou’s definition of integrated care 7.…”

Essential Information for Transition of Care for Frail Elderly Patients in Japan: A Qualitative Study

“…First, our study revealed that the current process of information transfer is suboptimal. Information lacking in the care transition process identi ed in previous studies include prior investigations 23 , medication 24 , and adequate attention to assessing comprehensive social conditions, especially among the elderly 25 . Our participants identi ed similar items, and all agreed that improving information transfer may improve the current care transition process.…”