Partners at Care Transitions


Funded by: NIHR Programme Grants for Applied Research
(1st January 2017 – 1st July 2022)
Principle Investigator: 
Rebecca Lawton  (
Programme Manager: Jenni Murray  (Email:

Older people are the highest users of the NHS and, with the number of people in the UK aged 75 and over set to double in the next 30 years, this group of patients is an important target for support to improve transitions of care. The aim of this research is to improve the safety and experience of care for older patients as they move from hospital to home.


Background information available here.

Recent News (October 2017 – 9 months into PACT):

Work package 1 – This is the first of our six work packages where we explore patient’s and caregiver’s experiences of care transitions from hospital to home.

NEWS: We have now completed recruitment and follow-up! We are now identifying patient and caregiver vulnerabilities that have important consequences for when patients return home from hospital. Loss of autonomy, poor communication, lack of receipt in the community and lack of involvement appear to be key vulnerabilities.  We are unpicking the causes of these so that we can target them during intervention development in Work package 4.  We continue to analyse the data. Click here for our recently published protocol paper.

Work package 2 – This involves trying to understand how some teams (primary care and hospital) manage to achieve low hospital readmission rates for older people.  Our key question is: What do they do to deliver safe care and to involve older patients during their transition home?

NEWS: Having identified the most successful teams through a data driven approach and conducted many interviews we are now analysing the data.  We have so far recruited 133 staff, conducted 10 focus groups in primary care, 8 in hospitals and carried out a number of observations and individual interviews.  Some really interesting findings are coming from these data relating to how patients help facilitate their own care by providing information to healthcare professionals and the importance of staff getting to know their patients.  More news to come……….

Work package 3 – This work involves developing a measure to assess the quality and safety of care transitions for older people that can capture the essence of the whole transition process.  We have drafted a list of items for our new measure based on a scoping review.  The measure is under development.

Work package 4This is where the fun really starts! Taking all the evidence from WPs 1 and 2, as well as existing evidence about transition interventions, to create a set of functional aims that services will need to address if they want to prevent key patient vulnerabilities.  We are learning from ‘complexity science’ and are not intending to ‘prescribe’ an intervention to different services.  Instead we aim to support services to turn the identified functions into locally-owned context-sensitive interventions. This link partly explains why we are using this approach –

New territory for research here…Lots of work, lots of decisions, lots of risks but we think it’s time to do things differently!

Patient Advisory Panel – Our group of keen and dedicated older adults have contributed to our research in a number of important ways. They have shared their experiences which have aided our data collection and have resonated with our findings and they have challenged our thinking about how we communicate our work and how to maintain focus on our core values.  3rd October Involvement Activity 2We are keen to involve them in a meaningful way and so have carried out a number of training sessions to facilitate their involvement in the process of developing our intervention. 3rd Oct Involvement activity 1 In our most recent activity (shown in the photos) the group worked through the challenging brain teaser that is patient involvement! It was an eye opener for them but also helped us gather a shared understanding about patient involvement.  Throughout PACT we will be gathering data that will help us evaluate how the panel contribute to the research.

Other linked work – In addition to these first three packages we are conducting a number of reviews within the transitions literature as well as a scoping review of transition innovations. The first of our reviews is now complete and we are in the process of writing this up for publication.  There’s a lot going on with quite a few publications planned, so visit this page on a regular basis for updates.  We also tweet regularly on our @PACT_YQSR twitter page.

This is independent research funded by the National Institute for Health Research (National Institute for Health Research Programme Grants for Applied Health Research, Partners at Care Transitions (PACT):  Improving patient experience and safety at transitions in care, RP-PG-1214-20017.  The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health.



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