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Conference Abstracts

Evaluating a transitional care programme for the average and the oldest old: a presentation of results from the quantitative phase of a mixed methods study


Wilma Van Der Vlegel- Brouwer ,

Advies/ 7Senses, Netherlands, NL
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Marjolein van der Vlegel,

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Jean Duckworth,

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Hazel Partington,

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Anneke de Jong

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Introduction and aim

In the Netherlands, the number of older adults of ≥85 years living independently increased by 10% in the last 10 years. In 2020, 3 out of 4 older adults were living independently. Older patients are at high risk of experiencing functional decline, and a decline in health-related quality of life and autonomy after acute hospitalization. During the transition from hospital to home, older adults are at risk for medical errors, communication related adverse events, problems in care fragmentation and re-hospitalisation. In the Netherlands, a pro-active, multi-component, nurse-led transitional care programme, called the Transitional Care Bridge (TCB) programme, was developed. A randomized clinical trial demonstrated a reduction in mortality but showed no other effects. The aim of this study was to describe the effect of TCB on functional decline, health care utilisation and self-management in a regional hospital in the Netherlands. This study is part of a larger sequential mixed methods study that evaluates the implementation of the Transitional Care Bridge.


All patients, aged ≥70 years, acutely admitted to the hospital, with an ISAR-HP ≥2 were included in this study. The transitional care programme was compared to usual care. The transitional care programme included a visit from the community nurse in the hospital, a handover of treatment plan by the geriatric team and five home visits after discharge. At three time points (at discharge, one and three months after discharge), patients reported on Activities of Daily Living (ADL) functioning, self-rated health, self-rated quality of life and health care utilization.


In total, 50 patients following the usual care path and 50 patients following the TCB programme were included in this study. Their mean age was respectively 84.6 and 84.0 years for patients following usual care and transitional care. The mortality rate within three months after discharge was lower in the transitional care group (n=3,, 6.4%) compared to the usual care group (n=6, 12.8%), although not statistically significant. Length of hospital stay were respectively 10.0 (SD:6.4) and 9.1 (SD: 3.9) days for patients with usual care and patients within the transitional care programme. There was no significant difference in hospital readmissions between patients with usual care and transitional care (p=0.795). Based on the Katz Index of ADL, 36.7% of patients in the transitional care group were dependent in ADL 3 months after discharge compared to 47.1% in the usual care group (p=0.401). Self-management, assessed by the community nurse with the Self Sufficiency Matrix (SSM) increased significantly in the transitional care group from 26.8 at discharge to 29.1 within 3 months after discharge (p=0.007).

Discussion and Conclusion

This study described the implementation and evaluation of the TCB programme in a regional hospital. It was expected that significant differences would be evident between the TCB arm and the usual care arm. A second phase of the study has been carried out involving interviews with professionals and patients. Analysis of the qualitative phase of the study may help to illuminate reasons for the lack of significance in the results.

How to Cite: Van Der Vlegel- Brouwer W, van der Vlegel M, Duckworth J, Partington H, de Jong A. Evaluating a transitional care programme for the average and the oldest old: a presentation of results from the quantitative phase of a mixed methods study. International Journal of Integrated Care. 2022;22(S1):97. DOI:
Published on 08 Apr 2022.


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