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 with a number of follow-ups also finished! Despite some initial concerns we retained many of our participants through a number of follow-up interviews.  We are very grateful to them for their time and openness.  Some of the themes that appear to be emerging from the data echo findings from previous research studies but because of our approach (seeing participants during a number of visits over time) we are shedding new light on what happens during transitions from hospital to home.  We continue to analyse the data. For more details about this work package look our for our protocol paper which will be published in BMJ Open soon ……watch this space for more info!

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 now identified the most successful teams through a data driven approach, we are currently setting up and conducting focus groups and interviews.  We have so far conducted one focus group with quite a few in the pipeline.  It’s too early to know what appears to work in practice but the hope is that the findings will help us to develop intervention strategies that are both realistic and sustainable in the real world.  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 scoped the literature for existing measures, looking for useful questions from measures but also gaps – we are keen to have a measure that doesn’t just rely on recall and that speaks very closely to the aims of our developing intervention.

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.

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.