Supporting care transitions for older people: a practice-based qualitative study in England

Care transitions in later life are challenging for older people and their carers. Social care practitioners, including social workers and other professionals, play a significant role in supporting these transitions, such as hospital discharges to care homes and moves between settings, but often face difficulties in providing effective support. This qualitative study explores the challenges experienced by older people, their carers and social care practitioners during transitions, and examines ways to improve transition-related practice. It involved semi-structured interviews with older people who have experienced or are planning to move (n = 6), family/friend carers (n = 11) and social care practitioners (n = 10). Using inductive data-driven thematic analysis, the study identified four themes: (1) unmet practical and emotional needs for older people and their carers, notably in decision-making; (2) barriers to effective practice, including communication, sourcing funding, and system challenges, such as a fragmented health and social care system; (3) strategies to improve practice, including person-centred strength-focused approaches, better communication and information access, and understanding diverse care settings; and (4) the importance of supporting practitioners. This study emphasizes the need to equip social care practitioners with necessary tools, training, and systemic support to facilitate proactive decision-making, and improve care transitions and outcomes for older people.