Impact of Post-Acute Transition Care for Frail Older People: A Prospective Study

To describe the characteristics and outcomes of frail older people in a post-acute transitional care program and to compare the recovery trajectories of patients with high and low care needs to determine who benefits from transition care.

Prospective observational cohort.

351 patients admitted to community-based transition care in two Australian states during an 11 month recruitment period.

Transition care provides a package of services including personal care, physiotherapy and occupational therapy, nursing care and case management post discharge from hospital. It is targeted at frail older people who, in the absence of an alternative, would otherwise be eligible for admission to residential aged care.

A comprehensive geriatric assessment using the interRAI Home Care instrument was conducted at transition care admission and discharge. Primary outcomes included changes in functional ability during transition care, living status at discharge and six months follow-up, and hospital re-admissions over the follow-up period. For comparison of outcomes, the cohort was divided into two groups based on risk factors for admission to high or low-level residential aged care.

There were no significant differences between groups on outcomes, with over 85% of the cohort living in the community at follow-up. More than 80% of the cohort showed functional improvement or maintenance of independence during transition care, with no significant differences between the groups.

Post-acute programs should not be targeted solely at fitter older people: those who are frail also have the potential to gain from community-based rehabilitation.