314 Cross-sectional analysis of patient cohort transferred to a transitional care unit under a new service model

Abstract

Abstract Background Currently in Ireland a proportion of hospital inpatients avail of ‘transitional care funding’ which has been in place in the HSE since 2015.The funding supports patients who are awaiting long term care placement or who require a convalescent period up to six weeks prior to discharge home. The aim of this project was to analyse the patient cohort transferred to the Transitional Care Unit (TCU) during a newly trialled model of care where a consultant geriatrician co-ordinated patient care. This new model aims for best practice by synchronising patient care through assessment, care planning, treatment, discharge planning and education. Methods We did a cross sectional analysis of the patient population who transferred from our model 4 tertiary hospital to the TCU under the new model of care over a 6 month period assessing their inpatient stay and discharge destination. Results 78 patients were transferred under the new model of care to this TCU unit. Patients were transferred from the emergency department (N = 1), medical (N = 55) and surgical teams (N = 22). 27% (N = 21) of patients had a documented cognitive impairment on admission to TCU, further testing was completed during inpatient period in TCU and a further 20% (N = 14) of patients had cognitive impairment identified. Bartel scores increased from admission to discharge with 54% of patients (N = 42). 62% went directly home or home with a home care package (N = 48), other discharge destinations from TCU included rehab or long term care. Conclusion This cross sectional analysis identifies the baseline characteristics of patients transferring into transitional care. This patient population remains vulnerable with significant number having cognitive deficits. Transitional care placement influence outcomes for older persons including returning home. Our study highlights that oversight and advocacy for patients entering transitional care is essential to optimise care.