A feasibility trial of the partners at care transitions (PACT) intervention

Inclusion criteria: 1. Aged 75 and over 2. Community‐dwelling at the time of admission and anticipated to be discharged to their own home or that of a relative (this can include a period of rehabilitation after hospital discharge) 3. Staying for at least one night on a participating ward 4. Ability to read and understand English 5. Willing and able to give informed consent (or personal consultee if lacking in mental capacity) For patients who lack capacity, eligible consultee/proxys (e.g. carers) will fulfil the following criteria: 1. A primary carer for the patient 2. Provides informal care to the patient (i.e. not paid / professional) 3. Willing to act as a consultee for the patient and/or willing and able to give informed consent to act as the patient’s proxy throughout the study. 4. Ability to read and understand English Exclusion criteria: 1. Out of area patients and/or patients who are to be transferred to another hospital 2. Admitted for psychiatric reasons (other than dementia/delirium) 3. Nursing/residential home resident or planning to be discharged to a nursing / residential home on a permanent basis 4. Less than one overnight stay (on the participating ward) at time of recruitment 5. Identified as being at the end of their life/subject to fast‐track discharge to palliative care 6. Unable to read and understand English 7. Unable to give informed consent and where a suitable personal consultee cannot be identified, or if no one is prepared to act as a consultee for the patient No specific condition. Patients will have been admitted to hospital for care for conditions such as stroke, COPD, infection, or with injuries from falls. It is not possible to know in advance what conditions the patients will have because we are recruiting from a range of hospital specialties which are likely to include stroke, respiratory, cardiology, and elderly medical wards. Patients may have dementia and/or acute delirium alongside their presenting complaint. Not Applicable 30‐day emergency hospital readmission measured using patient records 1. Safety and experience of older people during transitions from hospital to home measured using the Patient At Care Transitions Measure (PACT – M); Timepoint(s): up to 21, 30 and 90 days post‐discharge 2. Patient‐centred quality of care transitions measured using the Care Transitions Measure 3 items (CTM‐3); Timepoint(s): up to 21, 30 and 90 days post‐discharge 3. Quality of life measured using the EuroQol 5‐Dimension Health Questionnaire (5 levels) (EQ5D‐5L) and Proxy EQ5D‐5L; Timepoint(s): up to 21, 30 and 90 days post‐discharge 4. Healthcare resource use measured using an adapted version of Client Service Receipt Inventory (CSRI); Timepoint(s): up to 21, 30 and 90 days post‐discharge 5. Utility of the intervention measured using... A feasibility cluster randomised controlled trial will be conducted across 10 wards clustered within three acute NHS trusts. Wards will be randomised in an unequal allocation ratio (3:2) with six randomised to the intervention and four to usual care. Blinding will not used due to this unequal allocation. Recruitment and follow up of patients within each ward will take place over a 7 month period. Randomisation will be done using naïve minimisation with a base probability 1.0 (i.e. deterministic minimisation) will be conducted using the following key wards characteristics: ward type (speciality), the percentage of patients over 75 years, and NHS Trust. Intervention wards will deliver the Partners At Care Transitions (PACT) intervention ‐ a patient‐facing intervention which seeks to improve the safety and experience of older people as they transition from hospital to home. Control wards will deliver usual care to their patients. A minimum of 200 patients (approximately 20 patients per ward) will be recruited to participate in the trial. Participants will provide informed consent to: baseline data collection at the point of recruitment; follow‐up questionnaires to assess patient reported outcomes at three points post discharge (up to 21 days post discharge, 30 days and 90 days post‐discharge); and access to their medical records to gather routinely collected data (e.g. readmissions post discharge, and information about co‐morbidities). Depending on their preferences, patients may be followed‐up by post, telephone or email. At the 30 day follow‐up, if patients received a copy of the PACT intervention while they were in hospital, patients will be asked to return it to the research team. Within the sample of 200 patients, a nested sub‐sample of between 20‐24 patients will be recruited to participate in a qualitative assessment of feasibility. If relevant, the informal carers of these patie