Acute-Care Home Interface

Older persons hands

25 per cent of people aged 75 or over are readmitted to hospital within 30 days of being discharged. This percentage can increase when people are discharged from hospital to a care home. Many of these people have advanced frailty and end of life care needs that might be more appropriately met in a community setting.

Readmissions of people to hospital from care homes contribute to the fragmentation of care and are costly.

The Acute-Care Home Interface project was set up to:

  • Examine how to improve the discharge process, to reduce the rate readmissions to hospital and ensure people have a better experience of the discharge process
  • Develop community Proactive Elderly Advance Care (PEACE) documentation and support for advance care planning to reduce the rate of admissions to hospital and improve end of life care in care homes.

This has also helped develop and support the relationship between hospitals and care homes, as hospital admissions and discharge can have a detrimental impact on the well-being of our frailest residents.


Transfer of Care BundleTransfer of Care Bundle

To help improve the transfer of care processes and communication between hospitals and care homes a new Transfer of Care Bundle: Hospitals and Care Homes was designed and tested for several months.

The bundle sets out the best practice steps of a discharge which are contained within a discharge checklist and transfer forms needed for people moving from hospital to care home, and vice versa. This supports improved communication, collaborative working and early issue resolution.

The testing was successful and the bundle had a particularly positive impact on the quality of the discharge process and the experience for people. It has also helped develop the engagement between hospitals and care homes, through joint working and shared learning.

In April 2015 the bundle was launched at King’s College Hospital, so all patients who are transferred to a care home from King’s or who attend the Emergency Department from a care home in Southwark and Lambeth will use the bundle.


Care home and hospital resource packs

As well as launching the Transfer of Care Bundle, the project also developed and launched a Care Home to Hospital Resource Pack and a Hospital to Care Home Resource Pack.

The Resource Packs contain templates, guidance and important information which will help staff in both settings to transfer residents and patients to and from hospital when necessary.  This will allow care home and hospital staff to carry out safer, more coordinated and effective transfers of care, which will improve resident experience.

One of the main sets of documents within the pack is the Transfer of Care Bundle.  These resource packs have now been rolled out across the care homes in Southwark and Lambeth and across all wards in Kings College Hospital.


Final evaluation

In February 2016, a Final Report was completed and signed off by the project steering group. The main purpose of this report was to look at the expected outcomes and identify if the test achieved some or all of these outcomes and if there was evidence to demonstrate these. Key findings include a reduction in 30 day readmissions; during the test evidence demonstrated the transfer of care bundle had a positive effect on readmission rates, showing a reduction form 22 per cent across Southwark and Lambeth to 6 per cent within the test. Staff also reported building better and more effective relationships with their colleagues, as well as improved communication between groups of staff. In concluding the test and launch of the bundle, partners recognised that further work is required to continue to encourage use of the Transfer of Care Bundle across all settings and staff recognised the benefits of working together to ensure they provide a holistic approach to care for the frail, older population.

We have produced a one page summary of the report.


Evaluation Report
Bundle Documents