ABSTRACT

This chapter considers the important area of transitional care. Transitional care is an umbrella term that describes the period leading up to and following discharge from hospital. This period is particularly risky and complex, especially for older people who may have ongoing care needs, multi-morbidity and frailty. We apply the lens of incrementalism to transitional care. We explore why the design of services to meet specific local objectives rather than the needs of patients and families who pass through them, creates problems for both providers and receivers of care. We present evidence from our research on transitional care to explore the problems incrementalism creates and discuss how patients and families ‘reach in’ to support the safety gaps created by incrementally designed services across the transitional care continuum. We discuss the potential for interventions to systematically support patient and family involvement in transitional care, which might add to the resilience of this complex and risky system.