Transition care: will it deliver?

Gray, Len; Travers, Catherine; Bartlett, Helen; Crotty, Maria; Cameron, Ian D.

doi:10.5694/j.1326-5377.2008.tb01600.x

Cited by 24 publications

(23 citation statements)

References 4 publications

(6 reference statements)

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“…TCP targets older Australians at the conclusion of an acute hospital episode. The stated aims are to provide care that is goal-oriented, short term, therapy focused, and necessary to complete the care recipient's restorative process, optimise their functional capacity, and assist the older person and their families to make long term arrangements for care [16]. The average duration of care is 7 weeks, with a maximum duration of 12 weeks, that may in some circumstances be extended by a further 6 weeks.…”

Section: Discussionmentioning

confidence: 99%

How effective are programs at managing transition from hospital to home? A case study of the Australian transition care program

et al. 2012

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Background An increasing demand for acute care services due in part to rising proportions of older people and increasing rates of chronic diseases has led to new models of post-acute care for older people that offer coordinated discharge, ongoing support and often a focus on functional restoration. Overall, review of the literature suggests there is considerable uncertainty around the effectiveness and resource implications of the various model configurations and delivery approaches. In this paper, we review the current evidence on the efficacy of such programs, using the Australian Transition Care Program as a case study. Discussion The Australian Transition Care Program was established at the interface of the acute and aged care sectors with particular emphasis on transitions between acute and community care. The program is intended to enable a significant proportion of care recipients to return home, rather than prematurely enter residential aged care, optimize their functional capacity, and reduce inappropriate extended lengths of hospital stay for older people. Broadly, the model is configured and targeted in accordance with programs reported in the international literature to be effective. Early evaluations suggest good acceptance of the program by hospitals, patients and staff. Ultimately, however, the program's place in the array of post-acute services should be determined by its demonstrated efficacy relative to other services which cater for similar patient groups. Summary Currently there is a lack of robust evaluation to provide convincing evidence of efficacy, either from a patient outcome or cost reduction perspective. As the program expands and matures, there will be opportunity to scrutinise the systematic effects, with lessons for both Australian and international policy makers and clinical leaders.

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Section: Discussionmentioning

confidence: 99%

How effective are programs at managing transition from hospital to home? A case study of the Australian transition care program

et al. 2012

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“…It is also more akin to restorative care, with the expectation of slow gains over time with good supportive care and minimal therapy, than to intensive specialist rehabilitation. A recent article in the Journal highlighted concerns about the cost‐effectiveness of this program compared with alternatives, including rehabilitation 17 …”

Section: Problems With the Current Organisation And Delivery Of Rehabmentioning

confidence: 99%

Functional improvement of the Australian health care system — can rehabilitation assist?

New

Poulos

2008

Medical Journal of Australia

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Summary Strategies for managing increasing health system demand have focused on the acute sector and chronic disease management in the community, with little attention on the role of rehabilitation. There were over 53 000 inpatient rehabilitation episodes in Australia in 2006. We argue that rehabilitation can improve patient flow and outcomes in acute care if engaged early. The effectiveness of rehabilitation can be enhanced by increasing the intensity of therapy and developing models of rehabilitation that provide alternatives to inpatient care. Factors that reduce the efficiency of rehabilitation services include the location of many services in small, stand‐alone hospitals without acute support; the lack of options for managing younger people with acquired disability in the community; and deficiencies in government programs for the supply of aids, equipment and home modifications. Improving the organisation of rehabilitation services should improve access to acute and rehabilitation inpatient beds, improve patient outcomes and reduce costs.

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“…To be eligible, an older adult must be assessed as needing the level of support of at least low level residential care while in hospital for an acute care episode. Services provided by the transition care program include case management, medical and nursing support, rehabilitation services and personal and domestic care over a maximum period of 12 weeks (average seven weeks) post discharge from hospital [4]. The aim of the transition care program is to enable older persons to return home, rather than prematurely enter residential care, and to optimise their functional capacity.…”

Section: Introductionmentioning

confidence: 99%

Quality of life of older frail persons receiving a post-discharge program

Comans

Peel

Gray

et al. 2013

Health Qual Life Outcomes

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BackgroundA key goal for services treating older persons is improving Quality of Life (QoL). This study aimed to 1) determine the QoL and utility (i.e. satisfaction with own quality of life) for participants of a discharge program for older people following an extended hospital episode of care and 2) examine the impact of the intensity of this program on utility gains over time.MethodsA prospective observational cohort study with baseline and repeated measures follow up of 351 participants of the transition care program in six community sites in two states of Australia was conducted. All participants who gave consent to participate were eligible for the study. QoL and utility of the participants were measured at baseline, end of program, three and six months post baseline using the EQ-5D and ICECAP-O. Association between the intensity of the program, measured in hours of care given, and improvement in utility were tested using linear regression.ResultsThe ICECAP-O yielded consistently higher utility values than the EQ-5D at all time points. Baseline mean (sd) utility scores were 0.55 (0.20) and 0.75(0.16) and at six months were 0.60 (0.28) and 0.84 (0.25) for the EQ-5D and ICECAP-O respectively. The ICECAP-O showed a significant improvement over time. The intensity of the post-acute program measured by hours delivered was positively associated with utility gains in this cohort.ConclusionsA discharge program for older frail people following an extended hospital episode of care appears to maintain and generate improvements in QoL. The amount of gain was positively influenced by the intensity of the program.

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Transition care: will it deliver?

Cited by 24 publications

References 4 publications

How effective are programs at managing transition from hospital to home? A case study of the Australian transition care program

How effective are programs at managing transition from hospital to home? A case study of the Australian transition care program

Functional improvement of the Australian health care system — can rehabilitation assist?

Quality of life of older frail persons receiving a post-discharge program

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