Care transitions for frail, older people from acute hospital wards within an integrated healthcare system in England: a qualitative case study

Introduction: Frail older people experience frequent care transitions and an integrated healthcare system could reduce barriers to transitions between different settings. The study aimed to investigate care transitions of frail older people from acute hospital wards to community healthcare or community hospital wards, within a system that had vertically integrated acute hospital and community healthcare
services.
Theory and methods: The research design was a multimethod, qualitative case study of one healthcare system in England; four acute
hospital wards and two community hospital wards were studied in depth. The data were collected through: interviews with key staff (n =
17); focus groups (n = 9) with ward staff (n = 36); interviews with frail older people (n = 4). The data were analysed using the framework
approach.
Findings: Three themes are presented: Care transitions within a vertically integrated healthcare system, Interprofessional communication
and relationships; Patient and family involvement in care transitions.
Discussion and conclusions: A vertically integrated healthcare system supported care transitions from acute hospital wards through
removal of organisational boundaries. However, boundaries between staff in different settings remained a barrier to transitions, as did
capacity issues in community healthcare and social care. Staff in acute and community settings need opportunities to gain better understanding of each other’s roles and build relationships and trust.