Integrated transitions of care for people with geriatric syndrome

People with geriatric syndrome experience increased morbidity, fragility, cognitive decline and years lived with disability. Acute hospital length of stay has decreased, causing this vulnerable cohort to navigate fragmented community care. The risks of fragmented care may be mitigated by integrating informal caregivers into transitions of care. A systematic review examines whether integrating informal caregivers into transitions of care enables better outcomes, using the 'quadruple aims' framework for healthcare. Limited evidence of trends was found in this review. It may be that benefits of caregiver integration extend beyond the evaluation period of interventions. The systematic review highlighted gaps in current caregiver integration practice, research and policy, and informed a mixed methods study. The study investigates discharging planning from the perspective of eleven acute care physiotherapists. Their experiences suggest that caregiver integration is variable. The participants perspectives and experiences were used to construct experience-led solutions to ambiguous caregiver integration policy. Solutions vary from large-scale, such as restructuring funding models, to smaller-scale local solutions, for example interface changes in electronic medical record systems. Further high-quality research is required to investigate methods to successfully integrate informal caregivers, patients and health professionals into transitions of care between settings.