Good to Go: Enhancing care transfers from hospital to home for older people with complex needs.

Care transfers for older people with complex needs should be person-centred with effective multi -disciplinary teamwork (MDT) across hospital and community settings (Bolsch et al. 2005). This paper presents a project to enhance care transfers within Southwark and Lambeth Integrated Care (SLIC), which is a federation that promotes integrated care in south London, through bringing together general practices, acute hospitals, mental health care, social care providers and commissioning groups. This project comprised: Phase 1: Literature review of best practice in care transfers of older people; Phase 2: Scoping staff educational needs through: meetings with key individuals and teams, observation of MDT meetings; analysis of a local patient discharge survey; Phase 3: Development, delivery and evaluation of a one day interprofessional simulation course (‘Good to go: enhancing care transfers for older people’) for health and social care professionals