Differences in Clients Who Develop Home-Based or Community-Based Goals in a Transition Care Program: A Retrospective Cohort Study

The Transition Care Program (TCP) is a post-hospitalization rehabilitation program for older Australian adults. Consumers may develop home-based or community-based program goals. The objective of this study was to understand the differences between consumer cohorts who develop home-based goals only and those who develop at least one community-based goal. This single-site retrospective cohort study reviewed a local data set of consumers who accessed the TCP from 1/7/2014-31/12/2019. Goals were classified as either home-based or community-based and data was compared between these groups. Logistic regression models were used to determine predictors of nominating a community goal. Of the total TCP episodes, 1051 (99.3%) had goals and 694 (66%) had at least one community goal while the remaining made home goals only. The MBI score change (p<0.001), MBI score on TCP entry and exit (p<0.001), number of goals nominated (p<0.001) and discharge destination to an aged care facility (p<0.001) of patients in both groups were significantly different. Logistic regression indicated that age (p=0.029), number of goals nominated (p<0.001), and MBI on admission to TCP (p<0.001) were significant goal-type predictors. Older adults who develop community-based goals have a higher functional measure score upon admission and discharge from TCP. However those who develop home-based goals only have a larger change in functional outcome measure during TCP. Further research is warranted to investigate if setting community-based goals with all older adults will further improve outcomes for those who are more likely to set home-based goals only.