Old or frail acutely hospitalised patients can benefit from geriatric rehabilitation but criteria concerning referral decisions are unclear. This review presents an overview of clinical factors associated with referral to geriatric rehabilitation that may further consensus between hospital and rehabilitation professionals on triage. Scoping review. A review was conducted following Arksey and O’Malley’s framework. The search included literature concerning a broad spectrum of acutely hospitalised patients and factors associated with their referral to geriatric rehabilitation. Selected abstracts were categorised into distinct geriatric rehabilitation care pathways such as stroke, hip fracture, amputation of lower limb, cardiac and oncologic rehabilitation. Abstracts on internal medical patients were further reviewed and 29 studies were included. A total of 13 studies focused on factors identifying rehabilitation needs and 16 on factors associated with outcome of geriatric rehabilitation. Triage factors were diverse and included frailty status, functional decline, cognitive symptoms and multimorbidity. Mood symptoms and living situation further specified post-acute care needs. In overview, triage factors could be characterised as demographic (n = 4), diagnosis-related (n = 8), mental (n = 6), functional (n = 10) or multi-domain (n = 12) and mapped in a transitional care pathway. Frailty and functional decline are characteristics frequently associated with referral to geriatric rehabilitation of acutely hospitalised internal medical patients. A comprehensive geriatric assessment or a simpler multi-domain set of tests reveals rehabilitation needs and approximates a functional prognosis. Professional consensus on factors and timing of triage in hospital is within reach.

Purpose: To improve goal setting in Geriatric Rehabilitation (GR), by developing an evidence-based practical guideline for patient-centred goal setting. Methods: Participatory action research (PAR) in a cyclical process, with GR professionals as co-researchers. Each cycle consisted of five phases: problem analysis, literature review, development, practical experience, feedback & evaluation. The evaluation was based on video recordings of goal setting conversations, and on oral and written feedback of the GR professionals who tested the guideline. Results: In two PAR-cycles the guideline was developed, consisting of eight recommendations for setting and using goals, and of practical advices elaborating three of the recommendations, concerning conversational skills specific for goal setting conversations. After the second cycle the research team concluded that the guideline was feasible in daily practice and effective when used consciously. Conclusion: In this study, a practical guideline for setting and using goals in GR was developed. GR teams can improve their patient centred working with goals by discussing the recommendations in their team and choosing the recommendations to work on. This can be supported by the development of an interdisciplinary training. The effect on quality of care should be subject to further investigation.

Background: We assessed the vulnerability of patients aged ≥70 years during hospital admission based on the Short Dutch Safety Management Screening (DSMS). Screening of four geriatric domains aims to prevent adverse outcomes and may support targeted discharge planning for post-acute care. We explored whether the DSMS criteria for acutely admitted patients were associated with rehabilitation-oriented care needs.Methods: This retrospective cohort study included community-dwelling patients aged ≥70 years acutely admitted to a tertiary hospital. We recorded patient demographics, morbidity, functional status, malnutrition, fall risk, and delirium and used descriptive analysis to calculate the risks by comparing the discharge destination groups. Results: Among 491 hospital discharges, 349 patients (71.1%) returned home, 60 (12.2%) were referred for geriatric rehabilitation, and 82 (16.7%) to other inpatient post-acute care. Non-home referrals increased with age from 21% (70–80 years) to 61% (>90 years). A surgical diagnosis (odds ratio [OR]=4.92; 95% confidence interval [CI], 2.03–11.95), functional decline represented by Katz-activities of daily living positive screening (OR=3.79; 95% CI, 1.76–8.14), and positive fall risk (OR=2.87; 95% CI, 1.31–6.30) were associated with non-home discharge. The Charlson Comorbidity Index did not differ significantly between the groups.Conclusion: Admission diagnosis and vulnerability screening outcomes were associated with discharge to rehabilitation-oriented care in patients >70 years of age. The usual care data from DSMS vulnerability screening can raise awareness of discharge complexity and provide opportunities to support timely and personalized transitional care.

Transitioning older hospital patients to the appropriate type of post-acute care has become an urgent clinical issue within the context of changing demographics and limited duration of hospital stay. Consensus on assessments that guide post-acute care decision making would benefit potential patients and support cooperation between settings. A national web-based questionnaire focusing on professional contributions, patient involvement and the use of triage items and measures. Hospital and geriatric rehabilitation professionals in the Netherlands participated as respondent groups, representing 'sending' and 'receiving' professionals. A comprehensive questionnaire was used with open, multiple choice and closed questions, exploring in detail how assessment of hospital patients in need of a post-acute care decision was performed. Descriptive statistics were applied together with deductive coding of qualitative data. A total of 104 hospital liaison nurses (66.7 %) and 52 GR professionals (33.3 %) participated. Respondents were reasonably satisfied with the current triage practice. Hospital liaison nurses valued their operational responsibility for triage. Geriatric rehabilitation professionals wanted active involvement in decision making and deemed hospital paramedic expertise sub-optimally applied. 'Too little involvement' of patients and families was felt by 50.0 % of the GR respondents versus 15.5 % of hospital respondents. The importance of half (47.8 %) of the triage items was rated differently between respondent groups. When discussing complex cases between sending and receiving professionals, views were felt as complementary. Both sending and receiving professionals expressed moderate satisfaction with post-acute care decision making, whereas their views on triage assessments differed according to setting and role. The patients' voice may be insufficiently heard in triage decisions. Shared expertise and a consensual approach can develop when triage consultation is facilitated by both hospitals and PAC facilities. This study offers ingredients to reach a multi-professional view on post-acute care decision making and referral to geriatric rehabilitation.

Purpose: Geriatric rehabilitation is intended for older adults with vulnerability, comorbidity, and acute functional impairments. To explore and evaluate referral criteria, this study followed hospital patients referred for rehabilitation in nursing homes. Design: Exploratory, retrospective cohort study. Methods: Participants were community living before acute hospitalization and referred for geriatric rehabilitation between January 15 and May 15, 2019. Data were collected at hospital admission, hospital discharge, and discharge from rehabilitation-oriented care. Outcome measure was the final discharge destination. Results: Out of 87 hospital patients referred for rehabilitation (mean age = 76.3 years, SD = 10.7), 73 received rehabilitation-oriented post-acute care and 60 (82.2%) returned home after rehabilitation. Premorbid functional status was regained by 45 (61.6%) participants and mobility by 40 (54.8%). Independent baseline mobility, no complications during post-acute care, fewer cognitive symptoms, and multidomain vulnerability were associated with discharge destination after rehabilitation. Clinical Relevance to Rehabilitation Nursing: A multidomain assessment can make vulnerability applicable in referral decisions and induce tailored individual rehabilitation programs. Conclusion: This study explored the case-mix characteristics of hospital patients following rehabilitation trajectories. No frailty measures were available; vulnerability was refined into physical, cognitive, and social components. Careful assessment of vulnerability can support personalized referral decision-making.

Almost 30 % of older patients suffer from functional decline during hospital stay which often makes follow-up care decisions necessary. However, little is known about the topics that are relevant to these patients and their families to address in discharge conversations. This study aims to provide insight into the perspective of older surgical patients on follow-up care by exploring their considerations expressed throughout the process of discharge planning. A multi-method qualitative study. Participants were older patients from a surgical ward who anticipated to require follow-up care after discharge. Data collection included: 1) interviews with patients; 2) informal conversations with family members and professionals; 3) non-participant observations during medical rounds and bedside conversations; 4) extraction from medical records. In all data sources, the focus was on capturing the patients' considerations with regard to follow-up care. We employed inductive thematic analysis to identify needs that underlie patients' preferences for follow-up care. Twelve older surgical patients with complex or delayed discharge were followed. Their considerations with regard to follow-up care revealed five underlying needs: 1. Safety (adequate care), 2. Familiarity (trusted people and surrounding), 3. Independence (active and autonomous living), 4. Continuity (resume previous life) and 5. Relief (ending endurance). Most participants had more than one need. Older surgical patients' perspective on follow-up care can be captured by five underlying needs. Gaining insight into these needs contributes to a better understanding of patients' preferences for follow-up care. We therefore recommend exploring these needs in older surgical patients, as well as identifying potential similar or additional needs for other subgroups of older hospital patients, as an important step toward personalized decision-making in transitional care.