• Led by a team at East Kent Hospitals University NHS Foundation Trust, with a focus on patients admitted to William Harvey Hospital via the unscheduled care pathway.
  • Ran from October 2011 for two years.
  • Team aimed to improve communication during transfer of care processes, for frail and elderly patients.
  • Set out to develop a formal support structure for patients, carers and primary care providers following discharge.

A team at East Kent Hospitals University NHS Foundation Trust worked on a project to improve communication, during transfer of care processes, for elderly and frail patients. It focused on admissions to William Harvey Hospital via the unscheduled care pathway.

The team set out to confront the issue of inadequate clinical handover and discharge communication, as this was contributing to a high number of readmissions.

A system of electronic discharge communication had highlighted that clear clinical information was often lacking, such as responsibility for patient follow-up and changes to medication following reconciliation. In addition, GPs reported difficulties with providing follow-up care because of missing or ambiguous information.

The Comprehensive Geriatric Assessment (CGA) provides a multidimensional process designed to assess an elderly patient’s functional ability, physical health, cognitive and mental health, and socio-environmental situation. The project aimed to develop this framework to provide a formal support structure to patients, carers and GPs following discharge. The team planned to involve patients in designing the pathway using the experience-based design process.

The project aimed to ensure that every patient would have a written handover available before discharge to include the following:

  • reconciled problems list
  • physical functional status
  • care and formal support structures in place
  • a recorded advanced care plan and end-of-life preference
  • lead clinical contact details
  • a process for escalation in the case of patient deterioration
  • medicines reconciliation
  • clear follow-up processes.

Further reading

Research report

Safer Clinical Systems: Evaluation findings

December 2014
Research report

Lessons from the second phase of the Safer Clinical Systems programme.

About this programme


Safer Clinical Systems


A programme that ran in two phases from 2008 to 2013. It helped health care teams to proactively...

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