Returning home from hospital can be a difficult time, particularly for older people. The period of preparing to be discharged from hospital to settling in back at home is called a transition.  Sometimes transitions can be so difficult for people that they end up back in hospital again. It is thought that many hospital readmissions could be avoided.   The aim of this research is to improve the safety and experience of care transitions for older people (age 75+).

There are six work packages in this 5 ½ NIHR funded programme of research.  Each package takes us from understanding the problem and best practices around transitions, through to co-designing and refining an intervention and finally evaluating it.  Our evaluation will consider whether the intervention improves the experience and safety of care for older patients during transitions and reduce unplanned hospital readmissions. Please click on the links to explore each work package and its findings.


1 January 2017 – 30 July 2022

Work Packages

WP1 - Patient and caregiver experience of transitions

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.

WP2 - Staff Interviews

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.





WP3 – Developing a patient reported measure to assess the quality and safety of care transitions

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.

WP4 - Developing the intervention 'Your Care Needs You'

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.

WP5 - Feasibility testing of the ‘Your Care Needs You’ Intervention

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.

The protocol paper is published and can be found in the Publications & Outputs section below. Also in this section, there is a PACT Take Away which is an easy reading summary of our findings. A formal findings paper will be submitted for publication shortly.

WP6 - A cluster randomised controlled trial of the effectiveness and cost-effectiveness of PACT and parallel process evaluation

Status – started November 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:

Publications and outputs

Title Output Work Package Link
Going home from hospital – Patient experiences (patients and carers findings) Leaflet WP1 Click here
A qualitative study exploring the experience and involvement of older people moving from hospital to home Poster WP1 Click here
Hardicre, N. K, (2020).  SAGE Case Study – ‘Going Along’ or ‘Sitting Around With? Go-Along Interviews with Older People in Hospital to Understand Experiences at Transitions of Care [online] SAGE Research Methods Cases. https://dx.doi.org/10.4135/9781529740325 Paper WP1 Click here
Hardicre, N. K., et al. (2017). Partners at Care Transitions (PACT) Exploring older peoples’ experiences of transitioning from hospital to home in the UK: protocol for an observation and interview study of older people and their families to understand patient experience and involvement in care at transitions, BMJ, 10.1136/bmjopen-2017-018054 Paper WP1 Click here
Murray, J., et al. (2019). “How older people enact care involvement during transition from hospital to home: A systematic review and model.” Health Expect 22(5): 883-893. Paper WP1 Click here
Doing involvement: A qualitative study exploring the ‘work’ of involvement enacted by older people and their carers during transition from hospital to home. DOI: 10.1111/hex.13327 Paper WP1 Click here
Baxter, R., et al. (2018). “Partners at Care Transitions: exploring healthcare professionals’ perspectives of excellence at care transitions for older people.” BMJ Open 8(9): e022468. Paper WP2 Click here
Partners at Care Transitions? A qualitative study exploring the experience and involvement of older people moving from hospital to home Poster WP2 Click here
How to promote safety during transitions of care: A guide for CCGs and NHS Hospital Trusts.’ Output: Guide Report WP2 Click here
Oikonomou, E., et al. (2019). “Developing a measure to assess the quality of care transitions for older people.” BMC Health Serv Res 19(1): 505. Paper WP3 Click here
Baxter, R., Murray, J., O’Hara, J.K. et al. (2020) Improving patient experience and safety at transitions of care through the Your Care Needs You (YCNY) intervention: a study protocol for a cluster randomised controlled feasibility trial. Pilot Feasibility Stud 6, 123 (2020). https://doi.org/10.1186/s40814-020-00655-5 Paper WP5 Click here
Patient and Public Summary Leaflet WP5 Click here
Jane O’Hara, Karina Aase, Justin Waring. (2018) Scaffolding our systems? Patients and families “reaching in” as a source of healthcare resilience. BMJ Qual Saf Published Online First: 15 May 2018. http://dx.doi.org/10.1136/

bmjqs- 2017-007292


Click here
O’Hara J, Baxter R, Hardicre N.  (2020) Handing over to the patient’: A FRAM analysis of transitional care combining multiple stakeholder perspectives DOI:10.1016/j.apergo.2020.103060 Paper Click here
O’Hara J, Cranfield C, Aase K. (2019) Patient and family perspective in resilient healthcare studies: A question of morality or logic.       Safety Science 2019;120:99-106. Paper Click here


Further information

Click here for information on our PACT Patient and Public Involvement Panel.

For further information contact Professor Rebecca Lawton, Principal Investigator R.J.Lawton@leeds.ac.uk or Dr Jenni Murray, Programme Manager jenni.murray@bthft.nhs.uk 01274 383667

This summary presents independent research funded by the National Institute for Health Research (NIHR) under the NIHR Programme Grant for Applied Research (PGfAR) Award, reference RP-PG-1214-20017. Partners at Care Transitions (PACT): Improving Patient Experience and Safety at Transitions of Care.

We have published two papers (see the Publications and Outputs section below) from the work package reporting on the development and also the validation of the PACT-M measure.