Understanding and supporting older people's ‘transition’ between different care settings: Co-production of practice guidance for social care practitioners

Wenjing Zhang In progress  


Transitions between care settings in later life are challenging for older people but are also sometimes unavoidable. Staying in one’s own home as one gets older is often heralded as the ‘gold standard’. However, the home is not necessarily the only or best environment for ageing well, especially for people receiving high levels of care and support.

Transition is not only a physical move between care settings, but also a life event with social, psychological and emotional aspects. This may cause a number of ‘feelings of loss’ that can affect the well-being and identity of older people, such as loss of relationships, independence, belongings, choices and dignity. This highlights the needs and vulnerability of older people in transition.

Social care practitioners have a significant role in supporting older people and their families in transitions, but may lack understanding of the needs of older people and their carers as well as the confidence, guidance or resources in complex and unanticipated cases in practice. Social care practitioners have raised the need for a better and more consistent approach to preparing, communicating and supporting older people and their families. However, there is a lack of practice guidance in England on how to improve services pre-, during, and post transitions.


The aim of this study is to investigate how to facilitate social care practitioners in supporting older people and their families during their ‘transitions’ between and into social care settings.

It has been co-designed by social care practitioners and researchers.


The study includes two phases:

  • Phase 1 involves a rapid scoping review to synthesise what older people’s key (unmet) transition-related needs are and the approaches used by social care professionals in supporting the transition; and interviewing 10 social care practitioners, up to 10 older people and 10 family carers with lived experience of transitions (or supporting transitions) between social care settings/services (e.g. home care, care homes or extra-care housing) or from hospital into social care settings.
  • Phase 2 involves co-producing guidance through practitioner and public engagement, grounded in real-life experience through workshops.