Partners At Care Transitions

Project aims:

To help people prepare for being safe at home after discharge from hospital.  We know that people sometimes end up back in hospital after discharge and that this could be avoided with better preparation.  The risk of going back into hospital shortly after discharge is higher in older people. We wanted to know if helping people ‘know more’ and ‘do more’ in hospital would help them have a safer discharge. With a small group of older people, we developed the Your Care Needs You approach For patients and families – Your Care Needs You! (  This includes a booklet, advice sheet for managing at home, and a short video.  This encourages people to ask hospital staff questions, move about more and know about their medicines and their care.  Staff can be trained to deliver Your Care Needs You.

What you told us:

We tested Your Care Needs You across 11 hospitals.  Most of you liked the booklet and the advice sheet and you said you found them useful.  You didn’t see the video because it was on a hospital device that wasn’t shared with you.  A link to the video was on the back of the booklet but we don’t think people used it.

What we will do next:

When we tested the Your Care Needs You approach in the hospitals, we found that it helped people to avoid going back into hospital, that people had fewer bad experiences and that it was cheap to deliver.  We will work with other organisations offer this free approach across more hospitals.  We will find ways to help people access the video. The approach could be useful for anyone (and their families) preparing for a hospital admission.