Innovating Sustainable Transitional Care: Occupational Therapy Led Reablement

Abstract Background Older adults living with frailty admitted to acute hospitals are at significant risk of functional decline and loss of independence following discharge. Sustainable, age-friendly healthcare demands integrated, early transitional care models to support functional recovery immediately after acute hospitalisation. Occupational Therapy (OT) is uniquely positioned to lead such initiatives. Aim To design, deliver, and evaluate an occupational therapy-led post-acute transitional care model addressing deconditioning and hospital-associated disability, through collaboration between acute hospital and community home support services. Methods Funded by HSE Spark Innovation Funding, this pilot established an additional post-acute transitional care pathway on discharge from UHW: Healthcare assistants (HCAs) (home support) were retrained in reablement under OT supervision. Patients aged ≥65 admitted under orthopaedic and medical specialties were eligible. Intervention commenced at home on day zero or day one post-discharge. Outcomes included Barthel Index, EQ-5D Quality of Life, Life Space Mobility Assessment and Clinical Frailty Scale (CFS) among others, collected at baseline and end of service, with follow-up at three and six months. Service metrics (length of stay, number of visits, etc) were also tracked. Results In the first six months, the service saved c.170 acute hospital bed days and c. 450 step-down and rehabilitation bed days. 92% of patients discharged through the pathways did not require new or increased home support at discharge. Patient function improved as measured by Barthel Index and patient feedback demonstrated high satisfaction. Retraining HCAs (home support) to deliver rehabilitation was feasible and cost-effective. Conclusion OT-led, cross-sectoral collaboration delivering early, structured reablement post discharge reduces hospital-associated disability, promotes sustained functional recovery, alleviates healthcare system pressures while also providing timely access to care for older people. This scalable, sustainable model offers a clinically effective solution aligned with age-friendly healthcare principles.