Background: An increased focus has been placed on discharge planning, in order to reduce hospital length of stay and delayed discharges, and to improve continuity of care. Several benefits to team-based approaches for discharge planning have been noted; however, professional hierarchies remain. As such, challenges related to power dynamics are commonly experienced within teams who are dealing with care transitions for patients with delayed discharge. Further to challenges experiences, there remains a gap in understanding team dynamics across integrated care teams, specifically as they relate to discharge delays.

Objective: The objective of this study was to explore experiences with team-based discharge processes, specifically identifying what was working well and challenges encountered to outline how teams can function to better support transitions for patients experiencing a delayed discharge.

Methods: A descriptive qualitative study was conducted. Participants included hospital-based healthcare providers, managers, and organizational leaders who had experience with delayed discharges. Individuals were recruited from two diverse health regions in Ontario, Canada. Between December 2019 and October 2020, in-depth, semi-structured interviews were conducted in-person or virtually. The interviews were audio-recorded for transcription. Using a directed content analysis approach, data were analyzed both inductively and deductively.

Results: Thirty individuals participated in this study. The majority of participants were based in-hospital and held the following roles: social workers, discharge planners, clinical and project managers, physicians, and team leads. Despite being situated in hospital, several providers interfaced frequently with community organizations. We organized our findings into three main categories: (1) collaboration with physicians makes a difference; (2) leadership should meaningfully engage with frontline providers and (3) partnerships across sectors are critical. Participants described the importance of regular physician engagement, as equal members of the team, to improve consistent communication, relationship building between providers, and accessibility. A dedicated senior leader, who advocated for the team and ensured members of the team were treated as equals, was described as contributing positively to team dynamics. Cross-sectoral partnerships were enhanced by having an integrated community-based provider within the discharge planning team, placing focus on collaborative practice with combined discharge planning meetings, and physically embedding care coordinators in the hospital.

Implications: Based on our findings, recommendations for improving how teams function to support transitions for patients experiencing a delayed discharge include: consistent collaboration with physicians, engagement from senior leadership by seeking feedback from frontline providers through co-design, and active integration the community sector in discharge planning.

Conclusions: Team-based approaches for improving delayed discharge and supporting care transitions can offer a number of benefits. However, to optimize team dynamics and functioning across sectors for discharge planning, increased emphasis is needed on authentic engagement and integration across sectors.

Introduction: Early supported discharge (ESD) is well established as a model of health service delivery for people with stroke, allowing patients to return home sooner than otherwise would be possible to receive home-based rehabilitation, more than would be possible with standard community care. Emerging evidence indicates that ESD also reduces the length of stay for older medical inpatients. There is a dearth of evidence exploring the views of stakeholders on ESD as a model of care for older medical inpatients. The overall aim of this study is to explore the views and perceptions of older adults, family carers and healthcare professionals on the potential role of ESD for older adults
admitted to hospital with medical complaints.

Methods: A qualitative interview and focus group study was carried out at University Hospital Limerick (UHL) from November 2021 to January 2022. Purposeful sampling was used to recruit older adults who had been admitted to UHL and discharged home and their family carers for interview. Phone interviews took place with patients and their family carers following a semi-structured interview guide. For Healthcare Professionals (HCPs), snowball purposeful sampling was used to recruit those working with older adults in the acute and community settings. Focus groups for HCPs were moderated by A-MM. Braun and Clarke’s approach to thematic analysis was used. Ethical approval was granted by the HSE Mid-Western Area Regional Ethics Committee in November 2021 (REC Ref. 096/2021).

Results: Fifteen HCPs took part across three focus groups, with six older adults and two family members participating in one-to-one interviews. Three themes were identified:
1. Pre-ESD experiences of providing and receiving older adult inpatient care - identifying barriers to timely care; poor communication between HCPs themselves and HCPs and patients/families; and the impact of COVID-19 on health services for older adults.
2. Navigating discharge procedures from acute hospital services - discussing the impact of limited resources, both personnel and processes; the multifactorial nature of delayed discharges and subsequent adverse outcomes for patients; and the lack of integration between acute and community services in terms of IT and resources.
3. A vision for more integrated model of care and a medical ESD team - highlighting the need for ESD follow up to be timely; to be provided by senior staff with specialist skills; and the overall positive attitude towards an ESD team for older adults.

Discussion: This study provided insight into the current discharge experiences of older adult care in the acute setting, the potential role for ESD in this population and the key factors that would need to be considered for the running of an ESD service for older adults admitted to hospital with medical complaints.

Conclusion: This research highlights the barriers and facilitators to ESD for older medical inpatients from the perspectives of key stakeholders. Given the adverse outcomes associated with prolonged hospital stay, these findings will help inform the development of a cohort study, examining patient and process outcomes for older adults admitted to hospital with medical complaints who receive
an ESD intervention.

Introduction
Older adults frequently attend the emergency department (ED) and experience high rates of subsequent adverse outcomes including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. Health and Social Care Professionals are well placed to develop and lead integrated care intervention for older adults discharged from the ED (ED PLUS) to prevent and reduce these well reported adverse outcomes.

Objective
Our aim was to evaluate the feasibility of a physiotherapy-led integrated care intervention for older adults discharged from the ED (ED-PLUS).

Ethical Approval
Ethical approval was obtained from the HSE Mid-Western Area Research Ethics Committee (088/2020).

Method
Older adults presenting to the ED with undifferentiated medical complaints and discharged within 72 hours were computer randomised in a ratio of 1:1:1 to deliver usual care, Comprehensive Geriatric Assessment (CGA) in the ED, or ED-PLUS (Trial registration: NCT04983602). ED-PLUS is an evidence-based and stakeholder-informed intervention to bridge the care transition between the ED and community by initiating a CGA in the ED and implementing a six-week, multi-component, self-management programme in the patient’s own home. Feasibility (recruitment and retention rates) and acceptability of the programme were assessed quantitatively and qualitatively. In addition, a multi-stakeholder qualitative evaluation was completed using a semi structured interview approach. Functional status, quality of life and unscheduled ED re-presentation rates were examined post-intervention. All outcomes were assessed by a research nurse blinded to group allocation. Data analyses were primarily descriptive.

Results
Twenty-nine participants were recruited indicating a 67% recruitment rate. At 6 months, there was 100% retention in the usual care group, 88% in the CGA group and 90% in the ED PLUS group. ED PLUS participants expressed positive feedback about the intervention. There was a trend towards improved function and quality of life, and less ED revisits and unscheduled hospitalisations in the ED PLUS group. Nine older adults and six healthcare providers participated in the multi-stakeholder evaluation.

Conclusion
A pilot feasibility trial, ED PLUS, bridges the transition of care between the index visit to the ED and the community, for an older adult visiting the ED, is feasible using systematic recruitment strategies. Despite recruitment challenges in the context of COVID 19, the intervention was successfully delivered and well received by participants. There was a lower incidence of functional decline and improved quality of life in the ED PLUS group. Findings from this study will be used to refine the design and processes for a definitive RCT.

Introduction
Social and healthcare organisations are facing significant challenges in rebuilding care services after the COVID-19 pandemic, which were already under pressure due to demographic changes, including ageing and chronicity of the population and increased situations of dependency. These generate an increased number of hospital admissions, and in some cases longer stays due to a lack of social support at home.
Integrated health and social care systems can be at the forefront of providing a better response to these challenges, helping to maintain people’s autonomy to live in their own homes and remain independent for as long as possible.
In the development of new care models, active engagement of all stakeholders, including patients and caregivers, holds pivotal significance. Their input is vital to ensure the model aligns with real-world needs and is user-friendly.
Objective
The main objective of this study was to develop an innovative integrated health and social care model that incorporates home care services and technological support to enhance the transition from hospital to home for those elderly patients who lack the social support needed; with the ultimate goal to shorten hospital stays or avoid them when possible and improve patients’ wellbeing. This model was designed through a participatory design approach, involving care recipients, care providers, and all relevant stakeholders in the process to design a solution that is based on users’ needs.
Methods
A participatory design approach was employed to achieve the main objective of the study. Using design thinking and citizen participation techniques, the study was distributed across 4 phases: (1) Definition of the main target groups, carepathways and pathologies to focus on for the pilot, (2) understanding of the current pathways, the social and healthcare services ecosystem, and identifying patients, caregivers and healthcare professionals’ needs (3) online and in-person co-creation activities with patients, caregivers, healthcare and social care professionals, as well as home service providers, technology experts, and decision-makers to co-create the new integrated care model and service, (4) design of the final model and service to deploy a pilot for 18 months.
Results
As a result, a new integrated care service has been developed, based on users’ expertise and needs, to provide social & health home care support during the first 7-30 days post-hospital discharge.
The service encompasses four main elements that constitute this holistic support: (1) Daily support from a caregiver at home, and regular home monitoring by a technical multidisciplinary team; (2) A monitoring kit for remote health tracking and identification of warning signs; (3) A personal discharge folder containing self-care and prevention content with personalised recommendations for proactive engagement in their recovery; (4) A digital platform facilitating information management, alerts, and communication among stakeholders.
This innovative and integrated care approach aims to facilitate early return home, contributing to the patients’ recovery after hospitalisation while restoring autonomy and organising long-term support; ultimately enhancing patients’ well-being.

Introduction / Background:
Early Supported Discharge (ESD) after Stroke is an evidence-based service model which enables an accelerated discharge home after acute stroke by providing specialist rehabilitation and support within the community setting, most typically the person’s own home. This paper outlines the formation and development of the National ESD Network, a community of practice which enables teams to achieve and sustain successful implementation of the ESD model through professional development, standardisation of approach, peer support, shared values, and connectivity across professions, sites and stakeholders.

Who:
While ESD has been embedded within a small number of sites in Ireland since 2012, the pandemic was a catalyst for the development of the network for two reasons. One, there was increased expansion in Early Supported Discharge services, many of whom were rapidly established using transient funding streams, and secondly, there was a lack of opportunity to meet informally at conferences or other learning events. There are currently eleven ESD teams in Ireland, with a total workforce of approximately 50 people. These make up the network, together with the members of the national clinical programme for stroke and imminently people with stroke.

Design, Implementation & Monitoring:
The network meet quarterly for three hours, with the first hour devoted to either an invited guest speaker, or a journal club. Invited speakers are decided through consultation with the group, with all members inputting via an annual questionnaire, but are often Irish researchers, suggested by the ESD lead or stakeholders and service providers within the third sector. This enables relationships to be built up between researchers and the ESD team members, and ESD team members have also used this forum to themselves conduct research. The journal club articles are selected with a specific emphasis on developing interprofessional competencies, and are carried out in randomly assigned breakout groups with a central discussion at the end. Often this article chimes with an item on the main meeting discussion and so serves not only to expand professional development, but also to harmonise language, terminology and common understanding across professions and sites, enabling discussion to be easily facilitated among the network.

Results & Impact:
The network has been evaluated highly by the members as seen informally by the growing attendance, lively engagement, and also as seen in more deliberate evaluation. The network has facilitated a number of further developments, including building consensus on datasets, an implementation guide, and the inclusion of people with stroke in the network from early 2024. In relation to workforce in particular, network members report that the provision of a supportive community of practice has increased satisfaction and retention in this area of practice.

Learning & Next Steps:
The number of ESD teams in Ireland is planned to double by 2026. The current network model has scalability built in, through inclusion of both small group and larger group discussion. An exciting next step will be the inclusion of people with stroke, particularly as we begin to further define our shared values.

Hospital discharge planning for people and their families/unpaid carers can be protracted to return home or a place of choice to meet their continuing needs. The Trusted Assessor provides the opportunity to focus on what matters and acts on behalf of and with the permission of multiple organisations, carrying out an assessment of health and/or social care needs in a variety of health or social care settings, avoid unnecessary in-patient stay in hospital. This session will explore the benefits of the Trusted Assessor role with examples of good practice and the importance of a dynamic discharge planning process is person-centred, joined up and integrated across health, social care and the third and independent sectors to improve people’s experiences and outcomes through the discharge to home first.