Developing an intervention to assist older patients’ communication with their GP practice after discharge from hospital

Context In the post-discharge period from hospital acute inpatient care, the older patient is at risk from a lack of joined-up care. Hospitals write discharge summaries to family medicine providers. Though patients/carers are often copied in, they seldom get a plain English version or space to discuss its contents. Family medicine is uniquely placed to help, but lacks structures, tools and funding to do so.

Objective The GP-MATE study has built a new intervention for family medicine and patients/carers through co-design. Our intervention aims to assist older patients/their carers to have better communication with their family medicine provider about their care after discharge, thereby improving patient safety outcomes. We are currently testing our intervention to see if it makes a difference for patients, their families or family medicine staff.

Study Design and Analysis This four-year NIHR funded study used Experience-Based-Co-Design informed by a patient experience film and ethnography in family medicine. We are conducting a mixed methods feasibility study of the intervention.

Setting Co-design in England in three separate geographical strands united by a national level meeting. Feasibility testing in 8 participating family medicine sites in England.

Population Studied ~600 family medicine patients participating in retrospective record review, 300 of whom will use our intervention. A subset of ~24 patients/their carers will be interviewed. Interviews with ~24 staff in family medicine who offered the GP-MATE consultations.

Intervention/Instrument GP-MATE patient-held instrument with accompanying staff toolkit. For further information see GP-MATE (warwick.ac.uk)

Outcome Measures Our feasibility study explores suitable outcome measures for a potential trial including hospital readmission, patient experience, primary care utilization and harm/error.

Results We showcase our patient-held instrument and staff toolkit and its implementation strategy. Early results from our 9-month feasibility pilot (commencing Spring 2024) will be presented.

Conclusions GP-MATE is a bespoke care transition intervention for older people built by and for family medicine and its patients. We anticipate that our findings will be useful to creators of complex interventions for primary care and those looking to improve the care of older people across care boundaries.