Overall, the TRANS-SENIOR objectives were met. At the end of the project the vast majority of the work had been performed as planned.
Some of the specific tasks could not be completed as doctoral candidates for two of the 13 PhD projects dropped out, and at a stage where a new candidate would not have sufficient time to perform the necessary work.
The COVID-19 pandemic also affected the planned work and led to a project extension (e.g. as doctoral candidates could not access healthcare settings where they needed to collaborate and collect data). Because of this, some of the original research plans had to be adapted, but this was always done in such a way that the research was meaningful for the original research objectives.
The work for WP1 led to a consensus-based definition of ‘avoidable care transitions’ and offers relevant assessment instruments. In addition, two care models (I-MANAGE and INSPIRE) that could add to the prevention of unnecessary care transitions were operationalised to serve the needs of older persons in the community, and first evaluations were done. An analysis for older persons’ requests for unplanned care however (evenings, nights, weekend) showed that over-triage and thus unnecessary care transitions were often found, thus indicating that triage protocols are insufficiently tailored to the care needs of older persons.
The work for WP2 indicated that transitional care innovations are necessarily multi-component interventions and can include elements such as education, transition coordinators, shared decision-making, support, counseling and involvement of informal caregivers. The research effort indicated that through a stronger focus on people, rather than health and safety requirements, smoother care transitions could be achieved. Though valued by stakeholders, and though such innovations can potentially impact on outcomes such as hospital re-admissions and ED visits, transitional care innovations are not easily implemented. Furthermore, dementia adds to further complexity of transitional care. Therefore support for older persons with dementia and informal caregivers should respond to their particular needs.
Results for WP3 identified various involvement methods for empowering older persons and informal care givers in decisions around their own care trajectories, as well as at the level of decisions around relevant policies for health and well-being. In addition to this, the research work resulted in the Transitional Care Assessment Tool in Long-Term Care (TCAT-LCT), a tool designed to assess how long-term care systems perform with a view to enabling good quality transitional care. Furthermore, the work provided an overview of factors that can help or hinder in the implementation of transitional care innovations, and developed a set of relevant implementation strategies to accelerate the uptake of transitional care innovations.
