Title: Partners at Care Transitions (PACT): Improving Patient Experience and Safety at Transitions of Care
Funder: Department of Health and Social Care

Abstract: Aims and Objectives: To investigate whether greater involvement of patients and their families can improve patient experience and safety at transitions of care. To achieve this aim we will: Develop a better understanding of the transitions process from the perspective of older people, their carers (WP1) and health and social care professionals (WP2). Use the knowledge generated above to develop a measure of the quality of care transitions (WP3) and the Partners at Care Transitions (PACT) intervention (WP4) and test acceptability. Test the intervention and measurement instruments and the trial methods (WP5). We will further refine the implementation strategy and conduct feasibility work to inform a full trial. Conduct a full RCT (WP6) with a parallel process and economic evaluation to evaluate the effectiveness and cost-effectiveness of the transitions intervention and establish how it is used in practice. Rationale: Improvements in patient experience and safety are at the centre of NHS Policy (NHS Outcomes Framework 2015/16), representing core outcomes against which NHS commissioners and providers will be held accountable. When a patient moves between different care organisations e.g. from hospital to home, they are particularly vulnerable to risk and they often report a poor experience of care. The NHS Future Forum reported that too often patients experience gaps in service provision, failures in communication, and poor transitions between services. The current research programme will directly address this issue by building on recent systematic reviews of transition interventions that suggests that greater involvement of patients and their families can improve patient safety and experience at the transitions of care. In this programme we will adopt a novel conceptual approach to safety, known as 'Safety II', which goes beyond a focus on past harm and explores what goes well and why, as well as more effective anticipation and response to signals (disruptions, gliches etc.) to prevent harm in the first place. This programme of work will build upon our existing expertise in patient involvement in safety, the measurement of patient experience and patient safety and elderly care to address the question of what resilience (the capacity to recover quickly from difficulties) looks like at transitions and whether resilience can be fostered through the greater involvement of patients and their families at transitions of care. Research plan: This research will be delivered through six work-packages. The existing research on transition interventions, experience of older patients at transitions and the measurement of quality at transitions has been, and will continue to be, reviewed prior to the commencement of the programme. Work-package 1 will employ different interviewing techniques, together with observations to help understand the patient/carer experience of care at transitions and generate ideas about how patients could be more actively involved. Thirty patients from two hospital Trusts will be interviewed at different points in their care transition. Work-package 2 will use a positive deviance approach to identify wards and community teams that manage, despite similar resource constraints, to have low rates of hospital readmissions compared to similar services. We will then explore how this is achieved through multi-disciplinary, multi-service focus groups. Work-package 3 will use findings from the literature reviews and work-packages 1 and 2 to develop a measure of quality of care at transitions, a secondary outcome measure for the trial. The reliability and validity of this measure will be assessed in two studies. Work-package 4 will use co-production to develop and assess the acceptability of the Partners at Care Transitions (PACT) intervention. Through collection of feedback from staff and patients, this work-package will also inform the implementation strategy. Work-package 5 will explore the feasibility of the PACT intervention and trial methodology to refine the intervention and inform the decision whether or not to proceed to a full trial. Work-package 6 will evaluate the implementation, effectiveness and cost-effectiveness of the intervention through a cluster randomised controlled trial which will collect data on readmissions 30 days after discharge for 7000 patients across 50 wards. A sub-sample (N=782) of these patients will be asked to complete measures of quality of transition and quality of life, 30 and 90 days post-discharge. Outputs and dissemination Outputs will include: Patient experience of transition resources (stories developed in work-package 1); A patient-centred transitions intervention (PACT); A Quality of Transitions measure; Strategies to foster resilience at transitions and to increase the uptake of an intervention across care settings. Findings will be disseminated through publications for different audiences, including patients, together with workshops and master classes with our local and national safety networks. Stakeholders (NHS England, Health Foundation, Academic Health Science Network etc.) will be actively involved on our steering group throughout the programme. Benefit to the NHS: Poor transitions result in harm to patients and huge cost to the NHS. The UK urgently needs rigorous research to better understand the experience of patients and to develop and evaluate patient-centred interventions.

Lay abstract: The aim of this research is to improve the safety and experience of care for older patients as they move from hospital to home, sometimes via intermediate care (support from health and social care services). This period is known as the 'transition'. Patients now spend less time in hospital than they did 10 years ago (5 days compared to 8 days). This can benefit both patients, who prefer to be at home, and hospitals, who can treat more patients if patient stays are shorter. However, this also means that patients leave hospital sicker with ongoing treatment needs (e.g. they may need wound or catheter care or changes to their medication). Therefore, the transition period can be a risky one, particularly for older patients with complex needs and who may be anxious, confused and disorientated. 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. Government policy, described in the NHS Outcomes Framework 2015/2016, focuses on improving the experience of patients and the provision of safe patient care. In this programme of research we will try to understand and improve the experience, and safety, of care for older patients during transitions and, by doing so, reduce readmissions and NHS costs. We will do this by undertaking a programme of six inter-linked studies (described as work-packages (WP)). In WP1, we will follow older patients from hospital to home, collecting information from them about their experience of care through interviews and observations. In the second WP, we will use routinely collected data to identify wards and community teams who manage to achieve low levels of readmissions and investigate how they do this. In the third WP we will develop a measure of the quality of transitions which will be tested further in WP5 and used in the main trial in WP6. In WP4 we will develop and explore the acceptability and use of a patient-centred intervention called Partners At Care Transitions (PACT) that supports the involvement of older people and their families in care. We will then test the feasibility of this intervention (WP5) before evaluating its effectiveness and cost-effectiveness. To do this we will compare the readmissions on wards where the PACT intervention is delivered with wards where usual care is provided across six hospital Trusts. We will also evaluate whether the PACT intervention improves patient experience, safety and quality of life and reduces NHS costs by collecting this information from a sub-sample of 782 patients who we will follow-up for 90 days after hospital discharge.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE