An evaluation of a transitional care programme for older adults in a general hospital in the Netherlands: Needs, preferences, and perspectives of the average old and the oldest old
Authors: Van Der Vlegel-Brouwer Wilma 
Published: January 2024

Aim: This research aimed to evaluate a transitional care programme for older adults who were acutely admitted to a general hospital, with a special focus on health outcomes and healthcare utilisation for the oldest patients and to clarify patients’ and health care providers’ perspectives on the care provided.
Background: Populations around the world are ageing, and many older adults have complex health problems owing to multimorbidity. Consequently, they experience many transitions in care. During the past decade, transitional care for older adults has become increasingly important in terms of safe transitions and prevention of adverse events during transitions.Research however, often leaves the oldest old and the most vulnerable out of scope.
Methodology and methods: A mixed methods research design, based upon pragmatism and critical realism, was used in a parallel convergent design study. Measurements in the quantitative phase of the study were based on the The Older Persons and Informal Caregivers Survey Minimal Dataset (TOPICS-MDS). Data from the hospital registry and questionnaires were used. In the qualitative phase of the study reflexive thematic analysis was used on data gathered in interviews with patients, hospital nurses and community nurses and two focus group meetings with the geriatric team, and staff and managers from the home care organisations.
Findings: The quantitative part of the study did not show any significant results of the effect of the Transitional Care Bridge (TCB) programme on the prevention of functional decline, health care utilisation and other health outcomes. However, the study revealed an increase in preventive care in the more frail TCB group. The qualitative part of the study reveals the programme was valued by patients, family members and professionals. The familiarity with the programme and personal attitudes of professionals may have influenced expectations and outcomes. Many patients enrolled in the programme were very frail and often unaware of the programme. As they often already received some kind of home care, patients were initially referred to the usual carers. The assessment of the care needs of the oldest patients to some extent fail to recognise what would contribute most to ageing well at home. Professionals in hospital as well as home care organisations struggled with motivation towards the programme and felt they still remained working within their silos. Professional roles were not always clearly defined, valued and reflected upon, and outcomes relating to collaboration reveal a gap between the different worlds of hospital and home.

Discussion: Different contexts, organisational interests, personal attitudes and lack of reflection have influenced collaboration and the delivery of the programme. Transitional care interventions should be redeveloped for and with the oldest adults and their informal caregivers and address their needs during the period shortly after discharge, and help them build structure into their daily routines, and resume activities and exercise. Reflective practices on shared values, implications and outcomes should be developed as a competence within and between all involved organisations of transitional care. More reflective and emergent research approaches are needed to inform policies on ageing well in place and prevention.