“There’s Something Missing in the Middle” Co-Designing and Pilot Testing a Care Coordination Service for Older People Transitioning from Hospital to Home

Older people returning home after unplanned hospital admissions often experience fragmented care, leading to poor health outcomes and rehospitalisation. Taking a person-centred approach, we co-designed and piloted a care transition service with older people, their carers, and health professionals, to improve the care of older people as they transitioned from hospital to home. We conducted five co-design workshops with healthcare professionals and older people who had experienced frequent hospital presentations, to explore ways to improve the transition from hospital to home. The workshops culminated in the co-design of a Care transition Coordinator (CTC) role. We undertook a 6-month pilot study in one metropolitan hospital in Adelaide, Australia, to determine the feasibility and preliminary effectiveness of the role from an older person and health system perspective. Descriptive data were extracted from Comprehensive Geriatric Assessments, action sheets, patient checklists, and hospital databases, while semi-structured interviews were conducted with service users, providers, and referrers and thematically analysed to provide qualitative insights into the service. Thirty-five older people were cared for by the CTC during their transition from hospital to home. The CTC was perceived to meet the needs of older people and was well received by older people, their families/carers, and referrers. However, there were some challenges to the feasibility of the service from a service-provider perspective. Our findings indicate that it is possible to engage frail, older people who are frequent hospital presenters in a co-design process, and to design services that are informed by, and meet their needs.