Background:
The transition of care from hospital to home is frequently considered a weak point in the care of patients with geriatric syndrome, defined in this study as advanced age and disability, vulnerability to poor health outcomes and/or significant co-morbidity. Poorly managed transitions may cause hospital readmissions, poor patient experience and increased system costs. Including informal caregivers, people not paid to provide aid, into transitions of care may provide better value care for vulnerable older adults and support integration between health and community care. This review evaluated transitions of care using the quadruple aims of health care policy: improved population health outcomes, patient and healthcare professional experience and reduced costs of care.

Objectives:
To determine whether including informal caregivers into transitions of care provides better value care, compared to a transitional care intervention with less or no caregiver engagement.

Methods:
Systematic and hand searches were conducted in Medline, Proquest, EMBASE, Scopus, CINHAL and in grey literature. Studies were included if the population met the criteria for geriatric syndrome, had a transitional care intervention which routinely provided an opportunity for caregiver engagement, and had a comparator group. Exclusion was a two-stage process, initial abstract and full text screen. Study exclusion was guided by a protocol and form at each stage. Data was extracted using forms based on the Cochrane Handbook for Systematic Reviews. Bias was assessed using Cochrane tools for randomised and non-randomised control trials. To ensure reliability, bias assessment was completed by two reviewers.

Results:
Studies identified 23 interventions that were included in the systematic review. The 113 outcomes extracted used 64 unique assessment tools. Caregiver outcomes were collected in seven studies. Population health was addressed by over 70% of the outcomes, commonly addressed through patient function, disability and readmissions. The patient and informal caregiver experience, frequently assessed through patient satisfaction was addressed in approximately a fifth of the outcomes. Where collected, cost of care was primarily captured through resource use and overlapped significantly with population health. The healthcare professional’s experience was considered in less than 2% of collected outcomes.

Discussion:
Diverse methods and ambiguous treatment fidelity regarding caregiver engagement complicates assessment of the treatment effect, given no consistent outcome measures were reported across the quadruple aims. When positive outcomes were reported, they were commonly presented as decreased readmissions, resulting in decreased costs. Informal caregiver engagement did not occur independently from other discharge interventions such as case management and early supported discharge. Healthcare professionals’ experiences were rarely considered in these studies.

Conclusion:
The literature provides insufficient evidence to estimate the effect of including informal caregivers into transitions of care for patients with geriatric syndromes, and is variable in methodological approach, in the outcomes measured and in quality.

Limitations:
Non-published literature, such as local quality analysis projects, investigating informal caregiver engagement may have been missed.

Suggestions for further research:
Additional evaluations of caregiver engagement specifically using a quadruple aim lens are needed to assess better value care interventions.

Other:
Funding provided by Macquarie University

Introduction
In British Columbia (BC), Canada, health systems centralization shifted services to population-dense cities within geo-politically defined geographies. Although intended to create structures to respond more efficiently to local needs, the result has been a reduction in rural and remote services. People living in rural and remote communities face disproportionate socioeconomic burdens related to navigating health care. With growing interest in providing care closer to home, rural communities face particular challenges. In BC’s interior, one healthcare organization serves more than 100 rural and remote communities, including 54 First Nations communities, across 250,000 km2. People travel vast distances, crossing multiple mountain passes through year-round intense weather to access care.

Methods/Theory
Our research question was: What are the experiences of patients, their families, and nursing care providers in transitions from a referral centre back to rural communities? This integrated knowledge translation study used narrative methods to document stories of people living in rural communities who were referred for care, but chose not to go. Our research team included patient and community voices, decision makers (i.e., administrative leaders), clinicians, students, and researchers—actively doing research with people who could affect change in response to the experiences of people living in rural communities.

Results
Findings highlighted the complexity of fragmentation within healthcare and transportation systems that interact with increasingly complex patient needs. Patients and families experienced emotional and financial hardship related to trying to get back home. Discharge planning and transportation coordination were frequently challenging for patients, their families, and their care providers—with limited participation of patients and families in the process overall.

Discussion
Embedded in the realities of living rurally and accessing healthcare are multiple assumptions. These assumptions occur at disparate governance points—from policy and decision-making domains outside the scope of the healthcare system to the daily practices of clinical and administrative staff involved in coordinating appointments, care, and transport. These assumptions can mask or entrench health and social inequities.

Conclusion
Rural communities face compounding inequities in navigating access to care, particularly in navigating transportation and getting back home. Using existing technology, improving the ways in which systems collaborate between urban and rural communities, and supporting practical mechanisms for governance are essential pathways to ensuring centralized services do indeed serve the populations they are intended to serve.

Lessons Learned
We learned about the importance of supporting systems to know themselves, and validated the role research can play in facilitating this de-fragmentation process.

Limitations
Participants in our study felt compelled to shared their experiences because they believed their story offered an important lesson to learn from—which means their stories illuminate opportunities for improving. People whose experiences were benign or unremarkable are unlikely to share their stories

Suggestions for Future Research
Our study validates others exploring rural health priorities and challenges in BC, as well as studies evolving nationally and internationally. Future research will build on established relationships with rural communities to foster evidence and equity-informed governance and rural engagement in decision making.

Introduction:
South Eastern Sydney Local Health District (SESLHD) data highlights frail older people presenting to emergency, who once admitted have a longer average length of stay and often poorer health outcomes. In response, Uniting War Memorial Hospital (UWMH) created integrated rapid-response and anticipatory care programs to enable emergency avoidance, with the aim of keeping people well at home.

Practice change:
Since 2016, UWMH has undertaken systematic redesign at governance and clinical level to shift single-discipline care to integrated models providing co-ordinated and person-centred rehabilitation to older people with complex needs. This enabled creation of services including integrated Rehabilitation and Enablement Programme (iREAP), and Geriatric Flying Squad (GFS) establishing partnerships with Police, Ambulance and Residential Aged Care facilities (RACF’s).

Aim:
Integrating care in UWMH outpatient and community services from the ‘ground up’ enabled collaboration within the clinical team, using redesign to harness existing resources and expertise to deliver care differently. Early stakeholder engagement including gap analysis, consumer co-design, and integration of community, primary health and SESLHD resources created pathways for people across their health journey. This ‘ground up’ approach was enabled by Executive support, with appointment of an Allied Health and Integrated Care Manager to actively seek partnership opportunities and nurture integrated care innovations.

Targeted population/ stakeholders:
• Older people at-risk of deterioration, including frailty, falls, dementia and neurodegenerative conditions.
• Consumer feedback on service gaps and co-design to meet community need.
• Partnerships with primary health, GP’s, community providers, with structures to facilitate early referral.

Timeline:
Integration is an ongoing strategic priority, with plans for co-ordination of dementia services, and commencement of Health Justice Partnership (HJP) to tackle elder abuse.

Highlights:
An observational study of 99 iREAP patients demonstrated statistically significant outcomes including:
• Reduced frailty (Clinical Frailty Scale, 4.93 to 3.76 (P=0.0001) (Graphic 1))
• Reduced falls (5.17 to 2.02 falls at twelve month follow-up (p = 0.001)).
• Improved Patient Activation Measure (55.08 to 60.61 (p<0.001) (Graphic 2)), from ‘lacking confidence and knowledge’ with their health, to ‘beginning to take action.’

Reducing avoidable emergency presentations and premature RACF admissions; example in 2018, GFS treated 408 patients in partnership with nurses and GP’s within RACF’s, and further 21 emergency presentations avoided through GFS facilitating direct subacute rehabilitation admission.

Overall reduction in presentations to emergency by RACF residents (Graphic 3).

Sustainability:
Integrated services are now core business for UWMH, and success builds a platform for new initiatives including the HJP.

Transferability:
Redesign of existing resources, rather than additional funding, makes transition to integrated care achievable within activity based funding environment.

Conclusions:
Partnerships with community and GP’s, along with redesign through an integrated care lens, enables timely, effective and early intervention care for those with complex needs, enabling care in their place of choice and ability to self-manage in the longer term.

Discussions:
A ‘ground up’ approach, enabled by strong strategic support, are key enablers for integrated care models, challenging the traditional approach.

Lessons learned:
Early stakeholder engagement enables success, sustainability and reduction in duplication of services, improving co-ordination of care.

Potentially avoidable hospitalisation (PAH) rates for chronic conditions may be decreased by improved integrated care. This project was initiated in response to high rates of PAH and emergency department (ED) presentations for chronic obstructive pulmonary disease (COPD) to a sub-regional hospital.

PAH for COPD were assessed using hospital admission, ED presentation, and GP utilisation data. Patients who had been recently hospitalised with COPD completed a survey and interview regarding barriers and enablers to navigating the healthcare system and living well with COPD. Health professionals completed a survey regarding barriers and enablers to providing integrated care in the region. A reference group comprising of 18 people including health professionals, consumers, researchers and the Murray Primary Health Network met monthly.

The key challenges identified included gaps in coordination of care, difficulties during transition of care and inter-agency communication. The insights from the reference group informed strategies to address these challenges, namely a Transition Officer position and a patient controlled booklet. The strategies were implemented and evaluated from the perspectives of both patients and health professionals. At baseline 95 patients had been admitted over 12 months for COPD, 52 patients (55%) had repeat admissions (up to 6). 81 patients had presented to ED during this period, 25 (31%) on multiple occasions (up to 8). After 12 months, 101 patients were admitted over 12 months, 36 (36%) on multiple occasions (up to 5). ED presentations (75) and repeat presentations (10, 13%) had decreased, although other factors may have also contributed to these results. After hours GP services had decreased over the same time period.
Patients (n=38) provided feedback about the strategies. Of the 9 respondents who had seen the Transition Officer, 8-9 had received information about their condition, discharge process, post discharge appointments, medication and help at home. Of the 18 patients who had received a booklet, over half said that it had made a ‘very helpful difference’ in understanding their breathing difficulties, medications and exacerbation management. Health Professionals (n=28) provided feedback about the Transition Officer position (clear, consistent point of contact during discharge and more efficient referral processes) and the booklet (valuable tool to assist self-management).

The key barriers to integrated care were similar to those reported previously. The strategies described here are in keeping with recognised benefits of partnerships, engagement, communication and shared medical information.

The strategies described were designed to improve both communication between health professionals and integrated care, particularly during transitions of care. The strategies have shown promising results for patients in this regional Victorian setting, although more time and increased engagement with the strategies may be required to observe reductions in PAH. The Transition Officer has initiated several key improvements to complex care coordination and referrals have increased.

The inclusion of multiple, complementary data sources and high level of engagement of the multidisciplinary reference group were invaluable aspects of this project.

Small sample sizes and single clinical site limit the generalisability of findings.

Future research involves inclusion of a neighbouring rural hospital and contined monitoring of COPD PAH patterns.

Lahiru Russell1, Rebecca McIntosh2, Carina Martin2, Janine Scott2, Wee Kheng Soo2,3,4, Bernadette Zappa3, Kerry Haynes1, Patricia M Livingston1 and Anna Ugalde1
1 Deakin University Geelong Victoria, Australia, School of Nursing and Midwifery, Faculty of Health
2 Carrington Health Box Hill Victoria, Australia
3 Eastern Health Box Hill Victoria, Australia
4 Eastern Health Clinical School, Monash University, Box Hill Victoria, Australia

Introduction: Many people living with cancer do not receive adequate supportive care in oncology settings. Effective care coordination between oncology settings and community health could support survivors transition to allied health services and empower them to self-manage their health and wellbeing.
Description of practice change implemented: This study reports on the evaluation of a referral pathway from a hospital-based oncology service to a multidisciplinary community-based health service, Carrington Health.
Aim: The study aimed to understand patterns of service utilisation at Carrington Health, and health professionals’ perspectives on the implementation of a community-based model of survivorship care, the Good Life Cancer Survivorship (GLCS) program.
Targeted population: Survivors referred to GLCS were undergoing or had completed cancer treatment, and unable to participate in intensive ambulatory oncology rehabilitation.
Timeline: Carrington Health services utilisation was tracked over five months, and perspectives of health professionals referring to, and involved in the GLCS program were recorded using semi-structured interviews.
Highlights: The oncology service made 25 referrals. The most accessed services were physiotherapy with 18 appointments, followed by psychology (12) and dietitian services (11). Four themes emerged from the interviews: 1) Allied health services are relevant to people with cancer; 2) Education and information needs; 3) Communication gaps; 4) A one-stop multidisciplinary and holistic care model.
Sustainability: GLCS is a multidisciplinary cancer survivorship model integrated into an existing community-based chronic disease management program.
Transferability: Core components of GLCS could be implemented across other community health services to improve access to allied health services for all cancer survivors.
Conclusions: GLCS provides a model to support integrated allied healthcare services to help survivors transition from acute treatment to community-based care. Supporting ongoing awareness, education and understanding of services across both community and acute care settings will foster care coordination and strengthen referral pathways.
Discussions: Health professionals found the referral process acceptable and the program useful. A central point of contact for coordinating referrals and communicating information between acute and community health settings would help address communication gaps, reduce burden on clinicians and strengthen the model of care. Addressing specific communication and information needs of community allied health professionals will increase their confidence in discussing cancer specific needs with survivors. Discussing self-management and healthy lifestyle behaviour with survivors in the acute oncology setting will promote active discharge planning and aid transition of care.
Lessons learned: Accessing appropriate community-based allied health services will support survivors to develop self-management skills to manage their own health and improve their health outcomes and wellbeing in the survivorship phase.
Acknowledgments: The project was supported by the Victorian Government.