LAUSR

Demographic change continues to challenge health systems across the world, with older people accounting for the largest increase in hospital admissions [1]. Older people often have multifactorial health and social care needs that contribute to longer hospital stays that then expose them to iatrogenic complications, including medication errors, falls, pressure ulcers and delirium, contributing further to functional decline. An added problem is an increase in risk of being re-hospitalised, with 15% of patients ≥65 years readmitted within 28 days [2]. Each of these factors contribute to the importance of carefully coordinated discharge planning with supported hospital to home transitional care. Transitional care is defined as ‘a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location’ [3]. So, what are the goals of care transition? Clearly from a health system and patient flow perspective, reducing hospital length of stay (LOS) and unplanned re-admissions are important objectives. Additionally and importantly, are the patient-centred objectives of healthcare regarding quality of life, and restoration or maintenance of physical function such that patients are able to remain at home with or without support, for as long as possible. Both objectives should be achievable if there is a smooth transition from hospital to home. Provision of seamless integration of supportive care and services aims to optimise posthospitalisation outcomes and reduce risk of adverse events including unplanned re-admission. However, one of the challenges faced by hospital clinicians is coordination and integration of care across the acute community interface. Transitional care models are complex interventions encompassing multiple components. Success or failure is usually determined by the nature of the intervention, population and setting involved, and the outcomes measured to indicate effectiveness [4]. The potential obstacles of coordinating ongoing care were paramount in the development of the highly plausible comprehensive Community In-reach Rehabilitation and Care Transition (CIRACT) strategy reported on by Sahota et al. [5] in this issue. This multicomponent intervention provided inpatient rehabilitation, pre-discharge home assessment with relevant modifications, followed by seamless transfer to ongoing home-based care. The novelty of CIRACT was that all therapy services during and following hospitalisation were delivered by the same community team. Surprisingly, when compared with usual care, there were no differences in any of the hospital or patient-centred outcomes, with LOS as the primary outcome. This was in contrast to the pilot study that realised a shorter LOS in the intervention group (median difference −3 days) [6]. This raises a number of questions about how we can optimise the care transition of older, and over time, increasingly frail patients—which patients should we target, what goals should be achieved during hospitalisation to support safe discharge, what are the essential components of successful transition, what are the important outcomes, and when should they be measured to ascertain effectiveness?