Partners at Care Transitions (PACT)

Status – complete.

This was the first of our six WPs where we explored patient’s and caregiver’s experiences of care transitions from hospital to home.

Through our interviews and observational work we identified several key themes. These were:

• Valuing feeling cared for and supported;
• Loss of autonomy and independence;
• Poor communication;
• Confusion about medicines;
• Difficult discharges (either sudden & unexpected or drawn out and disorientating)
• Lack of receipt in the community;
• Lack of patient and carer involvement.

See the Publications and Outputs section below for all reports and conference presentations relating to this work package.

Status – complete

This involved trying to understand how teams (primary care and hospital) manage to achieve low hospital re-admission rates for older people. Our key question was: What do they do to deliver safe care and to involve older patients during their transition home?

We used routine data to identify wards and community teams who have low levels of hospital re-admissions. We then interviewed these teams.

Through our interviews with staff we found that:

• • Teams with established and trusted relationships that involve sharing of knowledge and concerns and where members value and understand each other’s roles;
  • Working creatively within inadequate discharge systems to ‘pick up the pieces’ and be ‘detectives’;
  • Empowering patients and helping them manage their own care and to navigate through the systems
  • Staff (including wider administrative team members) getting to know patients well to help with managing risk of hospital re-admissions.

See the Publications and Outputs section below for all reports and conference presentations relating to this work package.

Status – complete

We have developed a measure called PACT-M, which is made up of two parts:

• Part 1 includes 9 questions mostly relating to hospital care. This will be administered shortly after hospital discharge.
• Part 2 includes 8 questions about managing health care at home and this will be administered at around one month after discharge from hospital.

Both parts of the measure include questions about adverse events such as falls and infections.

The measure will be used in testing out the effectiveness of our intervention in WP6.

Both the development and validation of the measure have now been published.  See the Publications and Outputs section below for all reports and conference presentations relating to this work package.

Status – complete

Prior to working with stakeholders we took the findings from WP1 and WP2 to perform a mapping exercise to explore the key activities that patients need to undertake after discharge to manage their own health effectively. We then looked at opportunities that are available to prepare patients for these activities while they are in hospital.  The mapping process was called FRAM (see outputs below for our paper) and the key activities that we identified for the intervention are:

1) medicines;

2) health and well-being;

3) Getting moving;

4) knowing what to expect after discharge.

We aim to support older patients to be more involved in their care to ‘know more’ and ‘do more’ in hospital in advance of their discharge home. We involved a number of stakeholders (staff from health and social care and the third sector, and members of our patient panel) to help design the intervention.  The intervention called ‘Your Care Needs You! comprises a patient-held  booklet, a short patient film and enhanced discharge documents.  Staff will be supported to  encourage patient involvement across the four activities through behaviour change techniques.  We conducted a formative evaluation of the intervention and made changes based on patient and staff feedback.

We are currently writing reports on the development and pilot testing of the intervention and when these are available we will upload them to the Publications and Outputs section below.

Click on the image below to see a visual summary of our intervention development work.

Status – Complete

The trial feasibility study was conducted between November 2019 and April 2020. It involved nine wards from three hospital trusts. We have completed all data collection and follow-up and we are currently analysing the results. Knowledge gained from the feasibility trial has been invaluable and has been incorporated in the processes for the final full cluster randomised controlled trial in WP6.

A paper reporting the protocol for this study has now been published and can be found in the Publications and Output section below.

Status – delayed start due to COVID-19. Anticipate starting in early 2021.

Here we will assess the effectiveness and cost-effectiveness of the PACT intervention within a cluster randomised controlled trial. Our main outcome measure will be unplanned hospital re-admissions rates comparing wards where the PACT has been delivered to those where usual care is provided. We will also evaluate whether the PACT intervention improves patient experience, safety and quality of life using the PACT-M (see WP3 for more information) and reduces NHS costs.

The trial flowchart is shown below: