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Table 1 Evaluation of Transition Care

From: How effective are programs at managing transition from hospital to home? A case study of the Australian transition care program

Objective

Evaluation Findings

To defer admission to residential aged care

Of the initial 2,443 people approved for TC between 1 October 2006 and 31 March 2007, 1,204 (49%) received TC only in a community setting, 1,026 (42%) only in a residential setting, and 213 (9%) in both a community-based and a residential-based setting. By six months after entering the program, 47% had been readmitted to hospital at least once, 28% had been admitted to residential aged care for long-term care and 14% had died. Those TC recipients who received the program in a residential care setting only, were more likely to remain in residential aged care (n = 595 (58%)) or die (n = 209 (20%)) by six months. An audit conducted early in the program's implementation [21] confirmed that the residential-based services were providing packages to older people with severe disability and more complex care needs, who generally remained in residential aged care following completion of their TC episode.

 

Other factors associated with increased risk of residential aged care admission post TCP included increasing age (Odds Ratio (OR):1.05 (95% Confidence Interval (CI): 1.02-1.07)) and lower Modified Barthel Index (MBI) on admission (OR: 0.99 (95% CI: 0.98-0.99)) while increased hours of allied health services provided as part of TCP reduced the risk of admission (OR: 0.79 (95% CI: 0.67-0.94)).a

 

When the outcomes of the people who received TC were compared with other frail groups discharged from hospital in the same time period, the risk of admission to residential aged care in the six months post TCP approval was higher in the two control groups than among TC recipients overall (Control 1 OR: 1.9 (95% CI:1.5-2.3); Control 2 OR: 1.2 (95% CI: 1.0-1.4)).a

To optimize functional capacity

Evidence for a functional outcome of TCP is routinely assessed by the Modified Barthel Index (MBI), measured at admission and discharge. The national evaluation showed the average MBI at admission to TC was 64.3 units and at discharge was 76.9 units, representing an improvement of 12.5 units. However, without comparison groups, it is difficult to determine if the TCP program promotes accelerated recovery from newly acquired disability, compared with traditional approaches (including inpatient sub-acute hospital, day-hospital and community rehabilitation programs), and if such recovery is sustained over the medium or longer term [16].

To minimize inappropriate extended hospital lengths of stay

The national evaluation showed that the median length of stay for the index hospitalisation varied considerably between jurisdictions, making differences between TCP and control groups difficult to interpret. An earlier study assessing the effectiveness of moving patients who were waiting in hospital for a residential aged care bed to an off-site transition care facility [22] suggested that when all bed-days were counted, such units had system efficiency problems [15]. Although transferred patients 'saved' a median 11 (95% CI: 6-16) hospital bed-days, it took a median of 21 days longer (95% CI: 6-27) for them to be admitted to a residential aged care facility than those in the usual care group [22].b

  1. a Based on multiple logistic regression analyses that adjusted for cognitive status, total number of ADL items for which help was needed, availability of a co-resident carer, and Charlson comorbidity index at initial hospital stay.
  2. b Based on Mann-Whitney U-tests.