Identifying and overcoming challenges at the Transitions of Care

Fusion48 News

1 March 2015

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“Patients experiencing delayed transfers of care had trajectories of more general deterioration.”

The objective of the review was to understand the similarities and differences between the cohort of people with Delayed Transfers of Care (DTOC) in the acute setting and those people with successful transitions through Intermediate Care & Reablement services, and thus aimed to identify early opportunities for intervention to positively influence patient journeys and avoid dysfunction at later care transitions.

Many frailty themes were common to both groups and were articulated through three causative themes of delay within the DTOC group.   However, key differences also emerged.

  1. The DTOC cohort was younger but more dependent prior to admission than the Intermediate Care & Reablement cohort. 
  2. Although the mean number of co-morbidities was similar in the two groups, there were important differences in profile. In particular, the prevalence of dementia in the DTOC group was considerably higher than expected for the age of the cohort and compared to the IC&R cohort. Diabetes, cardiovascular and cerebrovascular disease were also more common in the DTOC cohort.
  3. The majority of the patients transitioning through IC&R services were previously independent and had a clearly identifiable acute precipitating cause for the index episode. By contrast, many patients experiencing DTOC had trajectories of more general deterioration against a background of already advanced frailty and high dependency. 

A summary of the work is available here.