Transitional Care Partners: A hospital-to-home support for older adults and their caregivers

2012 ◽  
Vol 25 (8) ◽  
pp. 407-414 ◽  
Author(s):  
Cristina Hendrix ◽  
Sara Tepfer ◽  
Sabrina Forest ◽  
Karen Ziegler ◽  
Valerie Fox ◽  
...  
Keyword(s):  
Older Adults ◽  
Transitional Care ◽  
Home Support ◽  
Care Partners ◽  
Hospital To Home

scholarly journals Challenges and Strategies to Maintain Fidelity to the MIRROR-TCM Intervention During the COVID-19 Pandemic

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. 235-236
Author(s):  
Mary Naylor ◽  
Karen Hirschman ◽  
Brianna Morgan ◽  
Molly McHugh ◽  
Elizabeth Shaid ◽  
...  
Keyword(s):  
Older Adults ◽  
Randomized Clinical Trials ◽  
Transitional Care ◽  
Skilled Nursing Facility ◽  
Chronic Obstructive ◽  
Obstructive Pulmonary Disease ◽  
System Leaders ◽  
Hospital To Home ◽  
The Impact ◽  
Challenges And Strategies

Abstract Randomized clinical trials (RCTs) have demonstrated that the multicomponent Transitional Care Model (TCM), an advanced practice registered nurse-led, team-based, care management strategy improves outcomes for older adults transitioning from hospital to home. However, healthcare systems’ adoption of the model has been limited. A multi-system, replication RCT (MIRROR-TCM) enrolling older adults hospitalized with heart failure, chronic obstructive pulmonary disease or pneumonia began in February 2020 just as the outbreak of COVID-19 in the U.S. dramatically changed the healthcare and research landscape. The goal of this qualitative descriptive study is to explore the impact of COVID-19 on fidelity to the TCM intervention during this clinical trial. Using directed content analysis, recorded monthly meetings with health system leaders and staff were coded to identify challenges and strategies to maintaining fidelity to the intervention in the context of the pandemic. Analyses showed that COVID-19 impacted all 10 TCM components. The components with the most challenges were delivering services from hospital-to-home due to quarantining, restrictive facility policies, lack of personal protective equipment and limited telehealth availability; coordinating care due reduced availability of services, and screening at risk individuals because of fewer eligible patients. Strategies for addressing challenges included: exploring alternatives (e.g., increasing reliance on telehealth, expanding study eligibility), building and engaging networks (e.g., direct outreach to skilled nursing facility staff) and anticipating needs (e.g., preparing for shorter hospital stays). Findings highlight the importance of monitoring the contextual challenges to implementing an evidence-based intervention and actively engaging partners in identifying strategies to achieve fidelity.

scholarly journals Feasibility and preliminary effects of an integrated hospital-to-home transitional care intervention for older adults with stroke and multimorbidity: A study protocol

2019 ◽  
Vol 9 ◽  
pp. 2235042X1982824 ◽  
Author(s):  
Maureen Markle-Reid ◽  
Ruta Valaitis ◽  
Amy Bartholomew ◽  
Kathryn Fisher ◽  
Rebecca Fleck ◽  
...  
Keyword(s):  
Older Adults ◽  
Transitional Care ◽  
Pragmatic Trial ◽  
Community Dwelling ◽  
Multiple Chronic Conditions ◽  
Rehabilitation Centre ◽  
Major Life ◽  
Web Based ◽  
Care Intervention ◽  
Hospital To Home

Background: Stroke is a major life-altering event and the leading cause of death and disability in Canada. Most older adults who have suffered a stroke will return home and require ongoing rehabilitation in the community. Transitioning from hospital to home is reportedly very stressful and challenging, particularly if stroke survivors have multiple chronic conditions. New interventions are needed to improve the quality of transitions from hospital to home for this vulnerable population. Objectives: The primary objective of this study is to examine the feasibility of implementing a new 6-month transitional care intervention supported by a web-based app. The secondary objective is to explore its preliminary effects. Design: A single arm, pre/post, pragmatic feasibility study of 20–40 participants in Ontario, Canada. Participants will be community-dwelling older adults (≥55 years) with a confirmed stroke diagnosis, ≥2 co-morbid conditions, and referred to a hospital-based outpatient stroke rehabilitation centre. The 6-month transitional care intervention will be delivered by an interprofessional (IP) team and involve care coordination/system navigation, self-management education and support, home visits, telephone contacts, IP team meetings and a web-based app. Primary evaluation of the intervention will be based on feasibility outcomes (e.g. acceptability, fidelity). Preliminary intervention effects will be based on 6-month changes in health outcomes, patient experience, provider experience and cost. Conclusions: Information on the feasibility and preliminary effects of this newly-developed intervention will be used to optimize the design and methods for a future pragmatic trial to test the effectiveness and implementation of the intervention in other contexts and settings.

scholarly journals Effectiveness of Transitional Care from Hospital to Home in Frail Older Adults: A Systematic Review

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. 821-821
Author(s):  
Ji Yeon Lee ◽  
Yong Sook Yang ◽  
Eunhee Cho
Keyword(s):  
Quality Of Life ◽  
Systematic Review ◽  
Older Adults ◽  
Health Status ◽  
Transitional Care ◽  
Frail Older Adults ◽  
Self Rated Health ◽  
Hospital To Home

Abstract Frail older adults are at high risk of negative consequences from hospitalization and are discharged without completely returning to their pre-existing health status. Transitional care is needed to maintain care continuity from hospital to home. This systematic review aimed to examine transitional care for frail older adults and its effectiveness. The Cochrane guidelines were followed, and search terms were determined by PICO: (P) frail older adults, not disease-specified; (I) transitional care initiated before discharge; (C) usual care; and (O) all health outcomes. Four databases were searched for English-written randomized controlled trials (inception to 2020), and eight trials were ultimately included. Frail older adults in eight trials (1996–2019) totaled 2,785, with a mean sample size of 310. The intervention components varied from hospital care (e.g., geriatric assessment, discharge planning, rehabilitation) to follow-up care after discharge (e.g., home visit, phone follow-up, community service). Most measured outcomes were readmission (n = 7), function (n = 4), quality of life (n = 4), self-rated health (n = 3), and mortality (n = 3). Statistical significance was reported in the following number of trials: readmission (n = 2), function (n = 2), quality of life (n = 1), self-rated health (n = 3), and mortality (n = 0). The effectiveness of the intervention on each outcome was inconsistent across the trials. Varied transitional care between hospital and home was implemented to improve health status; however, its effectiveness was controversial. A novel, yet evidence-based approach is needed to develop transitional care interventions for these vulnerable populations.

scholarly journals Perceptions of a Transitional Care Model for Older Adults With Multimorbidity and Depressive Symptoms

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 258-258
Author(s):  
Maureen Markle-Reid ◽  
Carrie McAiney ◽  
Rebecca Ganann ◽  
Carly Whitmore
Keyword(s):  
Older Adults ◽  
Depressive Symptoms ◽  
Transitional Care ◽  
Intervention Group ◽  
Structured Interviews ◽  
Community Assets ◽  
Provider Perceptions ◽  
Care Intervention ◽  
Hospital To Home ◽  
The Impact

Abstract Transitioning from hospital to home is an important healthcare system priority. This paper reports on the qualitative findings from a larger mixed methods study designed to examine the implementation and effectiveness of a new transitional care intervention (Community Assets Supporting Transitions [CAST]). The goal of the CAST intervention is to improve the quality and experience of hospital-to-home transitions for older adults (≥ 65 years) with depressive symptoms and multimorbidity. Semi-structured interviews were completed with a sub-set of intervention group trial participants including 11 older adult participants and 1 caregiver, as well as 4 intervention nurses. A qualitative descriptive design was used to explore the perceived impacts of the CAST intervention on participants and their caregivers. Audio-recorded interviews were transcribed verbatim, with descriptive codes and themes generated using conventional content analysis. Patient participants indicated that the intervention resulted in improved access to information (e.g., medication review) and services (e.g., care coordination) that enhanced their self-management. Participants felt that the home visits and phone visits were valuable and helped to improve their mental health. Intervention nurses described advocating for patients to help achieve their needs. For example, nurses advocated for physiotherapy services to provide additional education to support patient mobility. Understanding patient, caregiver, and provider perceptions of the impact of the CAST intervention will help to identify how to improve the delivery of this transitional care intervention, to bridge the gap between hospital and community care, and to positively impact patient health outcomes.

Helping Older Adults Assess Their Need for Future Home-Support Services

2019 ◽  
Author(s):  
Lee Lindquist ◽  
Kenzie Cameron ◽  
Jody Ciolino ◽  
Chris Forcucci ◽  
Dianne Campbell ◽  
...  
Keyword(s):  
Older Adults ◽  
Support Services ◽  
Home Support
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