Background: Increase in life expectancy in Ireland, and social isolation has led to an increasing number of people living in residential care facilities (RCFs). Residents are frequently transferred to Emergency Departments (ED) for a variety of reasons. Studies found up to 40% of these hospital admissions were deemed inappropriate. An inappropriate admission can be defined as “a situation in which care in lower cost settings would be as safe and less disruptive than care in higher cost hospital settings”.

Approach: A review of a convenience sample of ED attendances to University Hospital Kerry, Ireland (UHK) found that 50% were inappropriate. The SMART aim of the Quality Improvement Project was to reduce the number of persons residing in RCFs being inappropriately referred to University Hospital Kerry (UHK) from 50% to 30% from March 2024 to May 2025.
Quality improvement measures included the standardisation of terminology through the workings of the Palliative Frailty Multidisciplinary Team meetings, development of a communication document on resuscitation status and treatment escalation preferences and the implementation of an Advanced Nurse Practitioner (ANP) Palliative Care service for RCFs supported by a Palliative Medicine physician. Education was integral throughout the Quality Improvement Project.

Results: Quality improvement measures resulted in a reduction in monthly ED attendances of RCF residents from a median of 82 to 50. Inappropriate attendances reduced from 50% to 31%. Stakeholders’ feedback on the new service was overwhelmingly positive. The project resulted in financial savings for the Health Care Service.

Implications:
Integration of the Geriatric and Palliative Medicine services with staff of RCFs allowed for sharing of knowledge, standardisation of terminology, development of alternative models of care and pathways to access specialties. The introduction of a designated ANP Palliative Care service for RCFs has been essential in helping residents to receive the right care, in the right place, at the right time.

Background
Hospitalization often accelerates frailty, functional decline, and loss of independence among older adults. Evidence-based Acute Care for the Elderly (ACE) models mitigate these risks through interdisciplinary, person-centered care. Building on Southlake@home and the hospital’s ACE Unit, Southlake@home +ACE extends best-practice geriatric care beyond hospital walls into a coordinated hospital-to-home pathway—in partnership with CBI Home Health—delivering early rehabilitation, functional assessments, and restorative interventions to optimize recovery and support aging in place.
Approach
Southlake@home +ACE integrates hospital, home, and community care for older adults with complex medical and functional needs. The model builds on Southlake Hospital’s ACE Unit, providing targeted interventions within a senior-friendly environment led by geriatric-trained staff.
An embedded coordinator participates in daily ACE Unit rounds to identify eligible patients and initiate transition planning. Interventions are guided by a holistic assessment, functional independence index, and key geriatric assessment domains, emphasizing early mobilization, therapy engagement, proactive delirium and fall prevention, and co-designed care planning with patients, families, and caregivers.
Post-transition, patients receive a home visit within 24 hours for comprehensive geriatric assessment, medication reconciliation, and individualized restorative care planning. Coordinated nursing, therapy, behavioral, and social care interventions, augmented by remote patient monitoring (RPM) and real-time communication across the interdisciplinary team, ensure safety, continuity, and timely response to emerging needs. Ongoing assessment, digital monitoring, social prescribing, enhanced caregiver supports, and 24/7 clinical support further optimize recovery. Program evaluation uses a Quintuple Aim balanced scorecard with continuous feedback driving improvement.
Results
Within 16 weeks, 93% of patients met personalized goals, with functional improvements including 63% in balance and mobility, 63% reduction in frailty, and a 2.6-point average increase on the Modified Barthel Index. Reliance on acute care decreased: ED visits fell 64%, seven-day readmissions were 0%, 30-day readmissions 0.7%, and 75% avoided institutionalization.
Care metrics were strong: 100% received first home visits within 24 hours, 92% had medication reconciliation within 48 hours, and 77% had facilitated PCP visits within seven days. DIVERT scores improved (−55% risk of ED/hospital) and CHESS scores showed 94% improvement in frailty/instability. Falls risk decreased in 75% of patients, 100% were screened for social determinants, and 71% of caregivers reported reduced distress. System-level benefits included a 3.7-day reduction in hospital length of stay and an average 8.4 ALC days saved per patient. Provider experience remained high, with 96% reporting weekly “Joy in Work” and a 100% Net Promoter Score.
Implications
Southlake@home +ACE demonstrates that ACE principles applied across a hospital-to-home pathway improve outcomes while easing system pressures. Early supported discharge, integrated medical, rehabilitation, behavioral, and social supports, and person-centered care enhance transitions. RPM and real-time team communication strengthen responsiveness and continuity across settings. Ongoing engagement with patients, families, and caregivers reduces readmissions and ED use.
For international audiences, this model illustrates how aligning hospital, home, and community services under the Quintuple Aim can advance safety, independence, equity, and system sustainability. It offers a scalable, transferable framework for sustainable, outcome-driven, patient-centered care for older adults worldwide.

Background

The Home Hospitalization (HH) Service of ULS Coimbra, operating since October 2021, identified a critical gap in patient care: delayed access to home-based rehabilitation. Many patients—especially older adults recovering from orthopedic surgery, falls, or strokes—were waiting more than 30 days to begin rehabilitation. This delay often led to prolonged hospital stays or recovery at home without professional support, resulting in functional decline and higher healthcare costs.
To address this, the HH nursing team initiated a reorganization that placed rehabilitation at the center of integrated, person-centered care, ensuring timely, continuous, and equitable access to recovery services.

Approach

Launched in January 2025, the “Move+ at Home” project reorganized existing HH resources to create a rapid-response pathway for rehabilitation.
Three HH beds were designated exclusively for rehabilitation, managed by five specialist rehabilitation nurses. Key steps included:
• Promoting early referrals from Orthopedics and Neurology;
• Setting clear inclusion criteria (clinical, geographic, and social);
• Guaranteeing admission within 72 hours of referral (≤24h in some cases);
• Designing individualized rehabilitation plans with active involvement of patients and caregivers;
• Providing an average of 15 days of nursing-led rehabilitation supported by a multidisciplinary team (physician, pharmacist, nutritionist, and social worker);
• Ensuring structured discharge communication and continuity with primary care.
Future developments include the introduction of tele-rehabilitation tools and collaboration with municipalities to address social determinants and home accessibility barriers.

Results

Between January and October 2025, the project demonstrated measurable impact:
• 342 patients treated by HH; 47 included in the rehabilitation pathway.
• 100% admitted within 72 hours; 10 within 24 hours.
• Mean age >65 years, mostly female and referred by Orthopedics.
• Functional Independence Measure (FIM) improved from 70.8 at admission to 87.1 at discharge.
• All caregivers were trained in self-care and therapeutic management.
• Average hospital stay reduced by 7 days per patient, saving approximately €1,800 per patient and €84,000 in ten months (annual projection >€100,000).
• High satisfaction rates reported by patients, caregivers, and professionals.
• Positive environmental impact through reduced travel and efficient resource use.

Implications

Move+ at Home shows how a strategic reorganization of existing services can bridge a critical gap in access to rehabilitation. The model promotes functional recovery, strengthens caregiver capacity, reduces institutional costs, and contributes to environmental sustainability.
This is a low-cost, high-impact, and replicable model that any HH servisse can adopt. By transforming an access problem into an integrated, person-centered solution, the project advances the IFIC vision—demonstrating that integrated care can be achieved through innovation, collaboration, and smart use of existing resources.

Background:
It is estimated that approximately 19,000 people experience an acquired brain injury (ABI) in Ireland each year, which impacts significantly on quality of life for the person and their families. Unfortunately, the lack of community-based transitional rehabilitation services for people with an ABI leaving hospital, often results in many people being placed in inappropriate placements in nursing home facilities or being discharged home without supports.

Approach:
Acquired Brain Injury Ireland is a leading provider of community-based neurorehabilitation for people with an ABI in Ireland. In 2007, ABI Ireland, in partnership with the Health Service Executive, established the first transitional rehabilitation service for adults with an ABI in the Northwest of Ireland. The service provides short-term high intensity neurorehabilitation to four individuals at any one time and provides a rehabilitation pathway from hospital to home. This model focuses on enhancing the independent living skills of participants, by supporting the individual and their families to understand the impact of the ABI, and through the development of individualised neuropsychological and cognitive rehabilitation programmes. Support is provided in the service Monday to Friday, with individuals returning home to their families / community at weekends, to ensure transfer of their skills and strategies to their home environment. Rehabilitation is provided by Neuropsychology, Occupational Therapy and Rehabilitation Assistants on site and referrals can be made for Speech and Language Therapy and Physiotherapy. Upon discharge, a community-based rehabilitation team can continue to provide essential supports as the individual transitions home full-time. The model also allows for participants who previously accessed the transitional rehabilitation service to access a readmission to address new goals or prevent deterioration.

Findings:
Since its establishment, the transitional rehabilitation service has supported over 250 people with an ABI and their families. With 85% of admissions to the service coming from the acute hospital, the service provides a timely and direct route for ongoing rehabilitation before the person returns home. The average length of time from injury to admission into the service is 17 weeks; therefore, optimising the potential for rehabilitation and recovery. Most people who have accessed the service have successfully been discharged home within 12 weeks. From 2022 – 2023, data analysis of aggregated Mayo-Portland Adaptability Inventory – 4 outcomes demonstrated that participants (n=10) who accessed the service achieved a reduction in their limitations across all subsets; abilities, adjustment and participation.

Implications:
International research indicates that people with an ABI who access neurorehabilitation services earlier have better outcomes than those who access services later. Given the success of the transitional model, it is proposed that it be replicated to meet the needs of more adults with an ABI in Ireland.

Background. Adults with complex health and social care needs (hereafter complex needs) frequently experience transitions across care settings that require coordination across multiple providers. Poorly managed transitions increase the risk of fragmented care, medication errors, and preventable harm. Persistent challenges include poor communication, unclear roles, and limited discharge plans. While existing evidence largely focuses on clinicians, care transitions involve a broader range of professionals whose experiences remain underexplored. This study examines healthcare providers’ experiences of care transitions for adults with complex needs across community, primary care, and hospital settings. Approach. A descriptive qualitative study was conducted as part of a mixed-method research program across three sites in the provinces of Quebec and New Brunswick in Canada. Forty-six semi-structured interviews were conducted with a diverse range of healthcare professionals — including generalists, allied health professionals, specialists, and professionals working in community-based organizations and support programs — recruited through key informant sampling. Data were analyzed using inductive and deductive thematic approaches informed by a conceptual model of factors affecting care transitions. Results. Providers described interconnected challenges in care transitions at the patient, professional, and systemic levels. Socioeconomic vulnerability, housing instability, limited self-management, and patient decisions misaligned with clinical recommendations, complicated safe transitions, often forcing providers to balance patient autonomy with risk management. At the professional level, fragmented communication, lack of relational continuity with patients, informal coordination, insufficient planning, limited recognition of the expertise of certain professionals in community organizations, and restricted influence over care trajectories hindered care transitions. These issues point to the importance of clarifying professional roles and establishing well-defined processes for responsibility transfers across settings and actors. Systemic constraints, such as rigid eligibility criteria to access care programs and services, service saturation, and weak integration of external organizations and community partners, further limited responsiveness and contributed to structural inequities in care transitions. Providers often reported limited agency and feelings of powerlessness in addressing these issues, leading them to resort to solutions misaligned with patient needs. These factors collectively challenge the coordination and quality of care transitions for adults with complex needs. Implications. This study highlights how care transitions are shaped by interrelated factors at patient, professional, and systemic levels. Improving transitions requires not only better clinical coordination, but also attention to lived realities, professional agencies, and structural constraints. Strengthening cross-sector collaboration, clarifying roles, and embedding flexibility can foster safer, more equitable transitions for adults with complex needs.

Background: Individuals with complex health and social care needs often experience multiple care transitions across home, community, primary care, and hospital settings. These transitions create care fragmentation that compromises safety, autonomy, and overall wellbeing. This study aimed to identify individual and environmental factors associated with positive or negative care transition experiences among individuals with complex needs. Approach: A prospective correlational study was conducted across three sites in two Canadian provinces. Adults with ≥3 emergency department (ED) visits in the previous year were screened using the COmplex NEeds Case-finding Tool – 6 (CONECT-6). Those screening positive completed the INTERMED Self-Assessment (IMSA) to confirm complex needs. At baseline, participants completed validated questionnaires assessing sociodemographic, clinical, and psychosocial variables. Environmental variables were derived from geocoded postal codes, using national databases. Six months later, care transition experiences were assessed using a 12-item scale adapted from the Patient Experience of Integrated Care Scale (PEICS). Results: Of the 292 participants enrolled, 167 completed the six-month follow-up. The distribution of the care transition experience (dependent variable) had a mean of 30.71 (SD = 10.30) out of 52, with scores ranging from 2 to 48. Care transition experiences were significantly associated with biopsychosocial complexity, self-management capacity, and recruitment site. Participants with higher biopsychosocial complexity reported poorer experiences, whereas stronger self-management skills predicted more positive transitions. Implications: These findings emphasize that both individual complexity and self-management capabilities influence care transition experience. The observed differences between recruitment sites further suggest that organizational and systemic factors also play a role. The final regression model explained 16.6% of variance in care transition experiences, highlighting the need for further research on structural and contextual factors. Future research is warranted to more thoroughly investigate how organizational and systemic factors might better support individuals with complex needs as they navigate transitions across various care settings. For international delegates, this research offers insights into designing inclusive and integrated care models that are responsive to the realities of vulnerable populations such as individuals with complex health and social care needs.