Acute hospital services account for the largest proportion of health care system budgets, and older adults are the most frequent users. As a result, older people who have been recently discharged from hospital may be at greater risk of readmission. This study aims to evaluate the comparative effectiveness of transitional care interventions on unplanned hospital readmissions within 28 days, 12 weeks and 24 weeks following hospital discharge. The present study was a randomised controlled trial (ACTRN12608000202369). The trial involved 222 participants who were recruited from medical wards in two metropolitan hospitals in Australia. Participants were eligible for inclusion if they were aged 65 years and over, admitted with a medical diagnosis and had at least one risk factor for readmission. Participants were randomised to one of four groups: standard care, exercise program only, Nurse Home visit and Telephone follow-up (N-HaT), or Exercise program and Nurse Home visit and Telephone follow-up (ExN-HaT). Socio-demographics, health and functional ability were assessed at baseline, 28 days, 12 weeks and 24 weeks. The primary outcome measure was unplanned hospital readmission which was defined as any hospital admission for an unforeseen or unplanned cause. Participants in the ExN-HaT or the N-HaT groups were 3.6 times and 2.6 times respectively significantly less likely to have an unplanned readmission 28 days following discharge (ExN-HaT group HR 0.28, 95% CI 0.09–0.87, p = 0.029; N-HaT group HR 0.38, 95% CI 0.13–1.07, p = 0.067). Participants in the ExN-HaT or the N-HaT groups were 2.13 and 2.63 times respectively less likely to have an unplanned readmission in the 12 weeks after discharge (ExN-HaT group HR 0.47, 95% CI 0.23–0.97, p = 0.014; N-HaT group HR 0.38, 95% CI 0.18–0.82, p = 0.040). At 24 weeks after discharge, there were no significant differences between groups. Multifaceted transitional care interventions across hospital and community settings are beneficial, with lower hospital readmission rates observed in those receiving more transitional intervention components, although only in first 12 weeks. Australian and New Zealand Clinical Trial Registry ( ACTRN12608000202369 ).

Background: Chronic leg ulcers cause long term ill-health for older adults and the condition places a significant burden on health service resources. Although evidence on effective management of the condition is available, a significant evidence-practice gap is known to exist, with many suggested reasons e.g. multiple care providers, costs of care and treatments. This study aimed to identify effective health service pathways of care which facilitated evidence-based management of chronic leg ulcers. Methods: A sample of 70 patients presenting with a lower limb leg or foot ulcer at specialist wound clinics in Queensland, Australia were recruited for an observational study and survey. Retrospective data were collected on demographics, health, medical history, treatments, costs and health service pathways in the previous 12 months. Prospective data were collected on health service pathways, pain, functional ability, quality of life, treatments, wound healing and recurrence outcomes for 24 weeks from admission. Results: Retrospective data indicated that evidence based guidelines were poorly implemented prior to admission to the study, e.g. only 31% of participants with a lower limb ulcer had an ABPI or duplex assessment in the previous 12 months. On average, participants accessed care 2–3 times/week for 17 weeks from multiple health service providers in the twelve months before admission to the study clinics. Following admission to specialist wound clinics, participants accessed care on average once per week for 12 weeks from a smaller range of providers. The median ulcer duration on admission to the study was 22 weeks (range 2–728 weeks). Following admission to wound clinics, implementation of key indicators of evidence based care increased (p < 0.001) and Kaplan-Meier survival analysis found the median time to healing was 12 weeks (95% CI 9.3–14.7). Implementation of evidence based care was significantly related to improved healing outcomes (p < 0.001). Conclusions: This study highlights the complexities involved in accessing expertise and evidence based wound care for adults with chronic leg or foot ulcers. Results demonstrate that access to wound management expertise can promote streamlined health services and evidence based wound care, leading to efficient use of health resources and improved health.