The co-designed solution of a Care Coordination Service was pilot tested for 6 months in one hospital. Given the small-scale nature of the project, the evaluation focused on assessing the acceptability and feasibility of the service. This involved re-visiting our key stakeholder groups: those people receiving the service (older people and their family members), staff delivering the service (the nurse and allied health assistant) and staff referring into the service (for example, other hospital clinicians). Data were collected via documented records of care and interviews with the different stakeholder groups. The findings highlighted that the Care Coordination Service was well received by older people, their families/carers, and referrers, indicating a high level of acceptability. The service was seen to play an important role in bridging the transition from hospital to home, helping older people and their family navigate the complex aged care system, providing practical support, building confidence, and creating a set of ‘eyes in the home’ once the older person was discharged. Some issues with feasibility were identified from a service provider perspective, resulting in the recommendation to embed the care coordination roles within an existing community geriatric service.

Before subsequent scale-up of the Care Transition Coordination service, further research would be needed to establish whether the service is effective in terms of reducing hospital re-admissions, highlighting the ongoing and iterative nature of knowledge translation.

In our recent themed reablement Innovator Training Program (ITP) we explored the importance of goal setting to assist in the delivery of person-centred aged care. As all individuals have different needs and abilities, regular assessment is useful to determine how to assist older people with their physical function and cognitive abilities. This understanding allows us to set goals that are meaningful to each individual and motivates them to actively participate in their care.

Goal setting is a method used to negotiate goals to direct treatment and therapeutic support for older people and can improve the daily functioning of older people. It is important that older people are involved in the process of goal setting to ensure that goals have meaning and the potential to improve their quality of life. Aged care services should therefore consider the importance of goal setting and how meaningful goals can be integrated into everyday care delivery.