Table 2 Key themes and subthemes through which staff support safe transitions of care

Knowing the patient

Gathering a holistic picture

General Practice F: Knowing the patients was particularly important to preventing readmission and was considered far more effective than using the 2% high risk and frailty registers. Knowing patients well was evident throughout the practice team but was particularly evident with receptionists. They know who is high risk/vulnerable and will often notice this and take action when patients phone (e.g. squeeze them in for appointments). Knowing patients gives them context when looking at DNA [Did Not Attend] appointments so that they can mention it to GPs and chase or investigate non-attendance (i.e. for those who are frail). Pen portrait Line 29

Building trust and rapport

Community participants 3, 4 and 5: Many of their nurses are able to have conversations with patients about advanced care planning decisions such as DNARs. These conversations now tend to be led by community nurses rather than GPs, and they have found that the GPs will often now rely and refer these conversations on to their nursing team. The rapport that the nurses build up with patients supports them to have these conversations. Pen portrait Line 75

A shared understanding

Hospital A Ward B: Timely and targeted communication is another key to success – one AHP [Allied Health Professional] described his job as a 9 h MDT meeting. Formal communication mechanisms (handovers and board rounds) enable the team to get on the same page – everyone knows what is needed, by whom, and when to support timely discharge or transfer. The team prioritise tasks and individuals are challenged but at the same time supported by the MDT to achieve the things that are required within the necessary time frame. Communication throughout the rest of the day appeared to be very integrated across the MDT. Information is cascaded to other team members / professions on the ward as required. At times this will mean one staff member communicates the same thing to multiple people (nurses, HCAs [Health Care Assistant], Doctors etc). Pen portrait Line 41

Knowing each other

Feeling valued and listened to

Community participant 2: Based on comparisons with the other practices and her previous experience, the DN [District Nurse] Team Leader could see why the GP practice had been identified as having a low readmission rate. She perceived the general practice team to be ‘on the ball’, to work together, and to get on well. The DN felt that the GPs were approachable and that they would be listened to rather than being told ‘no’ or ‘I don’t have time’. Pen portrait Line14

Building relationships across boundaries

Hospital B: Each day a band 6/7 ‘ward coordinator’ (manager) works outside of the clinical staffing numbers (i.e. was supernumerary). They push things forward, liaise with others, and have time to develop relationship with the wider MDT / other services. These relationships help get things done. Pen portrait Line 107

Trusting one another

General Practice B: The doctors (although less so for the Practice Nurses) thought they had good relationships and trusted the DNs who are helpful, clinically good, and will escalate problems where necessary. ‘Knowing’ the DNs was key – talking to them and knowing their names. Pen portrait Line 94

General Practice F: The palliative care nurse mentioned that when she rings the practice she is confident that things will get sorted. Pen portrait Line 60

Bridging system gaps

Enhancing communication

General Practice A: GPs wanted to know about follow-up as soon as possible (i.e. when hospitals know a patient will be discharged) so that they could identify patients they are concerned about and plan additional care (based on their implicit knowledge about patients e.g. home circumstances). Currently they create reminders for themselves, or make appointments (e.g. on home visit list) for high risk hospitalised patients and keep putting them back if patients haven’t been yet discharged. Pen portrait Line 50

Adjusting patient expectations

Community participant 1: Although care would never be withdrawn from a capable patient who didn’t engage, increasingly DNs will say ‘no’ to patients, ask questions of them, set goals, signpost, and reassure patients to encourage them to self-care (rather that accepting non-engagement and doing things to patients). Pen portrait Line 48

Adapting to evolving services and competing priorities

Hospital A Discharge Liaison team: Multi-agency working facilitates efficient problem solving and is enabled by the teams having a better understanding of the barriers, concerns, challenges and pressures that other teams face. The teams can plan and coordinate care more effectively because they know who needs to do what, who has the specialist skills, and what everyone’s role is. Pen portrait Line 16