The development, implementation and evaluation of a transitional care programme to improve outcomes of frail older patients after hospitalisation.
fragmented healthcare systems are poorly suited to treat the increasing number of older patients with multimorbidity.



to report on the development, implementation and evaluation of a regional transitional care programme, aimed at improving the recovery rate of frail hospitalised older patients.



the programme was drafted in co-creation with organisations representing older adults, care providers and knowledge institutes. Conducting an action research project, the incidence of adverse outcomes within 3 months after hospital admission, and long-term care expenses (LTCE) were compared between samples in 2010-11 (pre-programme) and 2012-13 (post-programme) in frail and non-frail patients. Hospitalised patients aged ≥70 years were included in four hospitals in the targeted region.



developed innovations addressed (i) improved risk management; (ii) delivery of integrated, function-oriented care; (iii) specific geriatric interventions; and (iv) optimisation of transfers. The incidence of adverse outcomes was compared in 813 and 904 included patients respectively in the two samples. In frail patients, the incidence of adverse outcomes decreased from 49.2% (149/303) in the pre-programme sample to 35.5% (130/366) in the post-programme sample. The risk ratio (RR), adjusted for heterogeneity between hospitals, was 0.72 (95% CI: 0.60-0.87). In non-frail patients the incidence of adverse outcomes remained unchanged (RR: 1.02, 95% CI: 0.76-1.36). LTCE were similar in the two samples.



by involving stakeholders in designing and developing the transitional care programme, commitment of healthcare providers was secured. Feasible innovations in integrated transitional care for frail older patients after hospitalisation were sustainably implemented from within healthcare organisations.
Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, Netherlands.
Noor
N
Heim
Institute for Health Sciences, Radboudumc, Nijmegen, Netherlands.
Herbert
H
Rolden
Department of Psychiatry, Leiden University Medical Center, Leiden, Netherlands.
Esther M
EM
van Fenema
Department of Geriatrics, Diaconessenhuis Leiden, Leiden, Netherlands.
Annelies W E
AW
Weverling-Rijnsburger
Department of Geriatrics, Bronovo Hospital, The Hague, Netherlands.
Jolien P
JP
Tuijl
Department of Geriatric Medicine, Rijnland Hospital, Leiderdorp, Netherlands.
Peter
P
Jue
Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, Netherlands.
Anna M
AM
Oleksik
Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, Netherlands.
Anton J M
AJ
de Craen
Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, Netherlands.
Simon P
SP
Mooijaart
Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, Netherlands Department of Geriatrics, Bronovo Hospital, The Hague, Netherlands.
Gerard Jan
GJ
Blauw
Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, Netherlands Department of Public Health and Center of Healthy Ageing, University of Copenhagen, Copenhagen, Denmark.
Rudi G J
RG
Westendorp
Department of Psychiatry, Leiden University Medical Center, Leiden, Netherlands.
Roos C
RC
van der Mast
Directorate Medical Affairs, Leiden University Medical Center, Leiden, Netherlands.
Irma E C
IE
van Everdinck
D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D016330:Frail Elderly; D006299:Health Services for the Aged / Q000458:organization & administration / Q000592:standards; D006801:Humans; D008297:Male; D010351:Patient Discharge; D016730:Program Development; D015397:Program Evaluation; D058996:Quality Improvement / Q000458:organization & administration; D000069341:Transitional Care / Q000458:organization & administration / Q000592:standards
integrated care; quality improvement; transitional care