Understanding and supporting older people’s ‘transition’ between different care settings: co-production of practice guidance for social care practitioners

Moving (transition) between care settings in later life is challenging for older people but also sometimes unavoidable. Transition is not only a physical move between care settings, but also a life event with social, psychological and emotional aspects. Social care practitioners have a significant role in supporting older people and their families in transitions. However, there is a lack of practice guidance in England on how to improve services and support pre-, during, and post transitions.

Our project aims to provide practitioners, older people, unpaid carers (e.g. family and friends) and local decision makers with clear evidence and practice guidance for supporting older people’s transitions into and between different social care settings.

In this research we will:

• Review and summarise what older people’s key (unmet) transition-related needs are and the approaches used by social care professionals in supporting the transition;
• Interview social care practitioners, older people and unpaid carers with lived experience of transitions (or supporting transitions) between social care settings/services (e.g. home care, care homes or extra-care housing) or from hospital into social care settings.
• Co-produce guidance in partnership with older people, their carers and social care practitioners, grounded in real-life experience.

Research Objectives:

1. Synthesise the evidence about where the risks and unmet transition-related needs are. Moves to care homes, sheltered housing, specialist supportive housing and care in one’s own home will all be included.
2. Investigate how social care practitioners currently support and could better support older people’s transitions – this includes decision-making, mental health/preparation, social connections, etc.
3. Identify the transition-related experience and expectations of older people and their carers, their viewpoints on the risks and unmet transition-related needs, as well as personal examples of best practice.
4. Develop practice recommendations, aligned to the needs of older people, to guide practitioners during the process of supporting older people and their families pre-, during, and post transitions.

Funder/funding stream

NIHR School for Social Care Research (SSCR)

What are the main aims?

The overarching aim of this study is to investigate how to facilitate social care practitioners in supporting older people and their families during their ‘transitions’ between and into social care settings. Ultimately, we aim to provide practitioners, older people and their families, and local decision makers with coherent evidence and a practical toolbox that will be used to inform and support older people’s transitions into and between social care settings.

Key words

social care, older people, move, transition, co-production

Who benefits from the research?

This study will improve social care practice by offering guidance based on best-practice evidence and informed by the views of older people, their families and social care practitioners. The co-produced guidance will be publicly available and disseminated through our networks to reach care providers and their staff, advisory/consumer organisations as well as local authorities. To have maximum impact on care practice, it is important that we reach both sides of the transition – those referring people into services and settings, and those helping people adapt on the other side.
This co-production work will also build a better understanding between frontline practice and social care research. It will promote and improve the research capacity of social care practitioners via co-led research activities, dissemination and research capacity building events. This will inform and encourage future co-design and co-production in social care research and improve evidence-informed practice in the long term.

How is PPI embedded?

The co-production group of this proposed study will include around eight people with lived experience in adult social care, including users, family carers, social care practitioners, in addition to academic researchers in the project team. They will consult on the evidence collection of scoping review, interviewee recruitment, preliminary findings of scoping review and interviews, as well as work towards the co-production of practice guidance and be involved in dissemination events and creative outputs. With academic researchers’ support and training, two users/carers and two practitioners will also conduct some interviews and co-author the findings and other outputs.
Additional support or training will be provided by Amanda Bates (the Public Involvement Lead of Opening Doors to Research Group) in line with INVOLVE guidance, to ensure the user/carer research advisers are able to participate fully.