Pilot of a novel patient-led intervention for postdischarge from hospital management of older patients’ care in general practice

OBJECTIVE: General Practice Management After Transition Events (GP-MATE) is a codesigned patient-held tool to structure a dedicated postdischarge appointment for older patients. This pilot in routine general practice evaluated its feasibility (recruitment, tool use), acceptability (staff/patient views), potential outcomes (error, harm and readmission) and healthcare cost implications. DESIGN AND SETTING: Seven diverse general practices in the West Midlands, England, participated in this 4-year mixed-methods National Institute for Health and Care Research-funded study. A 20-minute GP-MATE appointment was offered to all patients aged >65 recently discharged from the hospital, supported by a paper-based communication tool sent to those who accepted. Three months of free-text electronic health records were reviewed for care use, intervention coverage, error, harm and readmission. Attributable healthcare costs were assessed. Patient/carer surveys and interviews with patients, carers and healthcare professionals explored experiences of delivery and use. PARTICIPANTS: 40 patients (mean age 75 years; 53% female) attended GP-MATE appointments, and 29 returned surveys. 17 patient-held GP-MATE forms were retrieved and analysed. Seven patients/carers and nine healthcare professionals were interviewed. RESULTS: =3.48 on 1df, p=0.06); no harms were detected. Postdischarge general practice use was high, with 115 admission-related contacts; almost two-thirds of the cohort had already received discharge-related care before GP-MATE. Despite this, GP-MATE appointments addressed persistent gaps in discharge information, leading to meaningful changes in care (mean=2.6 per patient), including new referrals and medication changes. Intervention costs represented just over half of the total mean attributable general practice care costs. Staff and patient/carer experiences indicate acceptability, though some unwell or confused patients struggled to differentiate the GP-MATE intervention from usual care. The perceived benefits were lower for elective or less complex admissions. Practices reported mixed experiences, including administrative difficulties in booking appointments and high non-attendance rates. CONCLUSION: GP-MATE was feasible to deliver, acceptable to staff and patients/carers and supported postdischarge communication. Larger trials are needed to establish robust evidence of readmission reduction and error/harm reduction, equity and cost-benefit.