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 data analysis! Through our rich data set have observed that patients experience a discharge from hospital rather than a transitions.  By this we mean that systems within the hospital are geared towards getting people fit for discharge and out of hospital.  This process does little to prepare people for life after discharge and so the first few days and maybe weeks can be very challenging for people.  The data also tell us about how patients can become very passive in hospital and the impacts of this on their post discharge experience.  We are focusing on this in our intervention development in Work package 4.  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: We have now completed data collection.  In the end we interviewed over 150 staff and conducted some observational work.  We are now analysing the data.  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 are currently taking the measure through a modified Delphi process and are almost ready to start piloting the measure.

Work package 4 – This is where we develop the intervention.  This is based on the learning from WP1, WP2, a review of existing transition interventions and some scoping work around locally developing interventions.  We have recruited a small group of health, social care and voluntary sector staff to help with co-production of the intervention.  The work is being facilitated by a Design Team based at Sheffield Hallam University who are using incredibly creative ways to get people to think outside their own experience.  We are keen that the intervention provides a way to support patients and their caregivers to be involved. Click here for our recent editorial paper which underpins some of this thinking.

Patient Advisory Panel – Our group of keen and dedicated older adults continue to support the research.  Most recently they attended our first intervention development group workshop.  Through the medium of Lego, they represented their experiences of being in and going home from hospital.  Great models were built much to the Wobbly legssurprise of some of our more cynical members, including the researchers!  Lego pathwayWe then combined the individual models to create a whole patient journey.  Representing the journey in this sense has staff and our panel members together in thinking about key areas of improvement.  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 publishing this.  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.



FREE DOWNLOAD – A new book aimed at supporting patients, families and carers of people going into hospital. The book is written by Charles, Dr Oliver Warren (consultant surgeon) and Bryony Dean Franklin (pharmacist) with long experience of working in hospitals and patients.