196 Models of transitional care, comparison of a new innovative consultant geriatrician lead service to current practice

Abstract Background The existence of short term (up to 6 weeks) HSE ‘transitional care funding’ has presented a potential discharge pathway for a proportion of hospital inpatients since 2015. These predominantly older, frailer patients access funding for beds that aim to support interim long term care placement or convalescence prior to discharge home. This project aimed to compare the existing ‘transitional care funded’ model of care in sites affiliated with our model 4 tertiary hospital to that of a newly trialled model where a consultant geriatrician co-ordinated patient care. This new model synchronises patient care through assessment, care planning, treatment, discharge planning and education as per best-practice. Methods Retrospective (January—September 2022) and prospective (September to December 2022) data collection of both care models compared Length of Stay (LOS), designation as a delayed transfer of care patient, discharge destinations (planned vs. actual), falls, allied health input, hospital readmission and death were compared between the two groups. Results A total of 131 patients (53 old 78 new model) were included. Average LOS in tertiary hospital was on average 30.0 versus 27.6 days. Average LOS in Transitional Care Unit (TCU) was 46 versus 25 days. A one way ANOVA was used to assess any statistical significance between the models of care across the following subheadings; death, change in Barthel Index, falls, discharge destination, readmission and sex. The one way ANOVA was statistically significant for LOS in TCU (p < 0.001), change in Barthel between groups (p < 0.001) and falls within TCU (p = 0.012). Conclusion The introduction of a new model of care at one of the TCUs has led to a significant reduction in length of stay. An opportunity to improve patient outcomes with the aim of establishing best practice have been identified. Transitional care placement influence outcomes for older persons including returning home. Our new model of care incorporates interdisciplinary teams and proactively target the complex patient’s care needs.