scholarly journals Building a Digital Bridge to Support Patient-Centered Care Transitions From Hospital to Home for Older Adults With Complex Care Needs: Protocol for a Co-Design, Implementation, and Evaluation Study (Preprint)

2020 ◽  
Author(s):  
Carolyn Steele Gray ◽  
Terence Tang ◽  
Alana Armas ◽  
Mira Backo-Shannon ◽  
Sarah Harvey ◽  
...  
Keyword(s):  
Older Adults ◽  
Phase 1 ◽  
Care Transitions ◽  
Self Management ◽  
Complex Care ◽  
Phase 2 ◽  
Care Needs ◽  
Centered Care ◽  
Hospital To Home ◽  
Complex Care Needs

BACKGROUND Older adults with multimorbidity and complex care needs (CCN) are among those most likely to experience frequent care transitions between settings, particularly from hospital to home. Transition periods mark vulnerable moments in care for individuals with CCN. Poor communication and incomplete information transfer between clinicians and organizations involved in the transition from hospital to home can impede access to needed support and resources. Establishing digitally supported communication that enables person-centered care and supported self-management may offer significant advantages as we support older adults with CCN transitioning from hospital to home. OBJECTIVE This protocol outlines the plan for the development, implementation, and evaluation of a Digital Bridge co-designed to support person-centered health care transitions for older adults with CCN. The Digital Bridge builds on the foundation of two validated technologies: Care Connector, designed to improve interprofessional communication in hospital, and the electronic Patient-Reported Outcomes (ePRO) tool, designed to support goal-oriented care planning and self-management in primary care settings. This project poses three overarching research questions that focus on adapting the technology to local contexts, evaluating the impact of the Digital Bridge in relation to the quadruple aim, and exploring the potential to scale and spread the technology. METHODS The study includes two phases: workflow co-design (phase 1), followed by implementation and evaluation (phase 2). Phase 1 will include iterative co-design working groups with patients, caregivers, hospital providers, and primary care providers to develop a transition workflow that will leverage the use of Care Connector and ePRO to support communication through the transition process. Phase 2 will include implementation and evaluation of the Digital Bridge within two hospital systems in Ontario in acute and rehab settings (600 patients: 300 baseline and 300 implementation). The primary outcome measure for this study is the Care Transitions Measure–3 to assess transition quality. An embedded ethnography will be included to capture context and process data to inform the implementation assessment and development of a scale and spread strategy. An Integrated Knowledge Translation approach is taken to inform the study. An advisory group will be established to provide insight and feedback regarding the project design and implementation, leading the development of the project knowledge translation strategy and associated outputs. RESULTS This project is underway and expected to be complete by Spring 2024. CONCLUSIONS Given the real-world implementation of Digital Bridge, practice changes in the research sites and variable adherence to the implementation protocols are likely. Capturing and understanding these considerations through a mixed-methods approach will help identify the range of factors that may influence study results. Should a favorable evaluation suggest wide adoption of the proposed intervention, this project could lead to positive impact at patient, clinician, organizational, and health system levels. CLINICALTRIAL ClinicalTrials.gov NCT04287192; https://clinicaltrials.gov/ct2/show/NCT04287192 INTERNATIONAL REGISTERED REPORT PRR1-10.2196/20220

scholarly journals Building a Digital Bridge to Support Patient-Centered Care Transitions From Hospital to Home for Older Adults With Complex Care Needs: Protocol for a Co-Design, Implementation, and Evaluation Study

10.2196/20220 ◽  
2020 ◽  
Vol 9 (11) ◽  
pp. e20220
Author(s):  
Carolyn Steele Gray ◽  
Terence Tang ◽  
Alana Armas ◽  
Mira Backo-Shannon ◽  
Sarah Harvey ◽  
...  
Keyword(s):  
Older Adults ◽  
Phase 1 ◽  
Care Transitions ◽  
Self Management ◽  
Complex Care ◽  
Phase 2 ◽  
Care Needs ◽  
Centered Care ◽  
Hospital To Home ◽  
Complex Care Needs

Background Older adults with multimorbidity and complex care needs (CCN) are among those most likely to experience frequent care transitions between settings, particularly from hospital to home. Transition periods mark vulnerable moments in care for individuals with CCN. Poor communication and incomplete information transfer between clinicians and organizations involved in the transition from hospital to home can impede access to needed support and resources. Establishing digitally supported communication that enables person-centered care and supported self-management may offer significant advantages as we support older adults with CCN transitioning from hospital to home. Objective This protocol outlines the plan for the development, implementation, and evaluation of a Digital Bridge co-designed to support person-centered health care transitions for older adults with CCN. The Digital Bridge builds on the foundation of two validated technologies: Care Connector, designed to improve interprofessional communication in hospital, and the electronic Patient-Reported Outcomes (ePRO) tool, designed to support goal-oriented care planning and self-management in primary care settings. This project poses three overarching research questions that focus on adapting the technology to local contexts, evaluating the impact of the Digital Bridge in relation to the quadruple aim, and exploring the potential to scale and spread the technology. Methods The study includes two phases: workflow co-design (phase 1), followed by implementation and evaluation (phase 2). Phase 1 will include iterative co-design working groups with patients, caregivers, hospital providers, and primary care providers to develop a transition workflow that will leverage the use of Care Connector and ePRO to support communication through the transition process. Phase 2 will include implementation and evaluation of the Digital Bridge within two hospital systems in Ontario in acute and rehab settings (600 patients: 300 baseline and 300 implementation). The primary outcome measure for this study is the Care Transitions Measure–3 to assess transition quality. An embedded ethnography will be included to capture context and process data to inform the implementation assessment and development of a scale and spread strategy. An Integrated Knowledge Translation approach is taken to inform the study. An advisory group will be established to provide insight and feedback regarding the project design and implementation, leading the development of the project knowledge translation strategy and associated outputs. Results This project is underway and expected to be complete by Spring 2024. Conclusions Given the real-world implementation of Digital Bridge, practice changes in the research sites and variable adherence to the implementation protocols are likely. Capturing and understanding these considerations through a mixed-methods approach will help identify the range of factors that may influence study results. Should a favorable evaluation suggest wide adoption of the proposed intervention, this project could lead to positive impact at patient, clinician, organizational, and health system levels. Trial Registration ClinicalTrials.gov NCT04287192; https://clinicaltrials.gov/ct2/show/NCT04287192 International Registered Report Identifier (IRRID) PRR1-10.2196/20220

scholarly journals Self-management in older adults: how to delineate self-management ability, self-management behavior, and self-management support?

2020 ◽  
Author(s):  
Klaske Wynia ◽  
Karin Veldman ◽  
Sophie Spoorenberg ◽  
Maarten Lahr ◽  
Menno Reijneveld
Keyword(s):  
Older Adults ◽  
Integrated Care ◽  
Elderly Care ◽  
Self Management ◽  
Complex Care ◽  
Management Support ◽  
Care Needs ◽  
Risk Profiles ◽  
Management Ability ◽  
Complex Care Needs

Abstract Background: Self-management is a key element in person-centered and integrated care. It involves several related concepts, such as self-management ability, behavior, and support. These concepts are poorly delineated. The aim of this study was to examine hypothesized associations between self-management ability, behavior, and support in older adults (taking their frailty and complexity of care needs into account) and to examine underlying aspects of these concepts, if these hypotheses lacksupport.Methods: Cross-sectional data from the Embrace study, a stratified randomized controlled trial, evaluating person-centered and integrated care in Dutch community-living older adults, were used. Participants (n=537) were aged 75 and older, assigned to health-related risk profiles based on self-reported frailty and complexity of care needs. Ability was assessed with the Self-Management Ability Scale, behavior with the Partner in Health Scale for Older Adults, and support with the Patient Assessment of Integrated Elderly Care.Results: Ability and behavior were positively associated for participants with the risk profiles “Robust” and “Complex care needs” (betas are 0.38 and 0.46). Coping (an aspect of behavior) turned out to be a key element for participants with risk profiles “Robust” and “Complex care needs” (betas ranging from 0.13 to 0.45). Support was associated with aspects of behavior, varying per risk profile.Conclusion: We found no associations for self-management on the conceptual level, but the aspect coping did appear to play a major role. Improving coping strategies of older adults may be a promising way of enhancing self-management ability, and of reducing the need for self-management support.

scholarly journals Geriatric Resource Teams: Equipping Primary Care Practices to Meet the Complex Care Needs of Older Adults

Geriatrics ◽  
2019 ◽  
Vol 4 (4) ◽  
pp. 59 ◽  
Author(s):  
Gwendolen Buhr ◽  
Carrissa Dixon ◽  
Jan Dillard ◽  
Elissa Nickolopoulos ◽  
Lynn Bowlby ◽  
...  
Keyword(s):  
Older Adults ◽  
Primary Care ◽  
Cognitive Impairment ◽  
Assessment Process ◽  
Complex Care ◽  
Care Needs ◽  
Care Practices ◽  
Primary Care Practices ◽  
Complex Care Needs ◽  
The Impact

Primary care practices lack the time, expertise, and resources to perform traditional comprehensive geriatric assessment. In particular, they need methods to improve their capacity to identify and care for older adults with complex care needs, such as cognitive impairment. As the US population ages, discovering strategies to address these complex care needs within primary care are urgently needed. This article describes the development of an innovative, team-based model to improve the diagnosis and care of older adults with cognitive impairment in primary care practices. This model was developed through a mentoring process from a team with expertise in geriatrics and quality improvement. Refinement of the existing assessment process performed during routine care allowed patients with cognitive impairment to be identified. The practice team then used a collaborative workflow to connect patients with appropriate community resources. Utilization of these processes led to reduced referrals to the geriatrics specialty clinic, fewer patients presenting in a crisis to the social worker, and greater collaboration and self-efficacy for care of those with cognitive impairment within the practice. Although the model was initially developed to address cognitive impairment, the impact has been applied more broadly to improve the care of older adults with multimorbidity.

scholarly journals How digital health solutions align with the roles and functions that support hospital to home transitions for older adults: a rapid review study protocol

BMJ Open ◽  
2021 ◽  
Vol 11 (2) ◽  
pp. e045596
Author(s):  
Hardeep Singh ◽  
Alana Armas ◽  
Susan Law ◽  
Terence Tang ◽  
Carolyn Steele Gray ◽  
...  
Keyword(s):  
Older Adults ◽  
Human Subjects ◽  
Digital Health ◽  
Phase 1 ◽  
Care Transitions ◽  
Health Interventions ◽  
Transitions Of Care ◽  
Rapid Review ◽  
Two Phase ◽  
Hospital To Home

IntroductionOlder adults may experience challenges during the hospital to home transitions that could be mitigated by digital health solutions. However, to promote adoption in practice and realise benefits, there is a need to specify how digital health solutions contribute to hospital to home transitions, particularly pertinent in this era of social distancing. This rapid review will: (1) elucidate the various roles and functions that have been developed to support hospital to home transitions of care, (2) identify existing digital health solutions that support hospital to home transitions of care, (3) identify gaps and new opportunities where digital health solutions can support these roles and functions and (4) create recommendations that will inform the design and structure of future digital health interventions that support hospital to home transitions for older adults (eg, the pre-trial results of the Digital Bridge intervention; ClinicalTrials.gov Identifier: NCT04287192).Methods and analysisA two-phase rapid review will be conducted to meet identified aims. In phase 1, a selective literature review will be used to generate a conceptual map of the roles and functions of individuals that support hospital to home transitions for older adults. In phase 2, a search on MEDLINE, EMBASE and CINAHL will identify literature on digital health solutions that support hospital to home transitions. The ways in which digital health solutions can support the roles and functions that facilitate these transitions will then be mapped in the analysis and generation of findings.Ethics and disseminationThis protocol is a review of the literature and does not involve human subjects, and therefore, does not require ethics approval. This review will permit the identification of gaps and new opportunities for digital processes and platforms that enable care transitions and can help inform the design and implementation of future digital health interventions. Review findings will be disseminated through publications and presentations to key stakeholders.

scholarly journals Addressing Needs of Older Adults in Low-Income Independent Living Facilities in Community Health

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. 328-329
Author(s):  
Lisa Rauch ◽  
Toby Adelman ◽  
Daryl Canham ◽  
Nancy Dudley
Keyword(s):  
Older Adults ◽  
Community Health ◽  
Low Income ◽  
Independent Living ◽  
Complex Care ◽  
Care Needs ◽  
Term Care ◽  
Undergraduate Nursing ◽  
Complex Care Needs ◽  
The Impact

Abstract Access to quality care in long-term care settings including independent living facilities is needed for a diverse high-risk aging U.S. population. There is an urgent need to assess and address complex care needs of older adults living longer with chronic conditions and serious illness. However, a system to assess and identify health problems, intervene, and evaluate outcomes is lacking. This session presents learnings from a pilot study developed in collaboration with Nurse Managed Centers at low-income independent living facilities for older adults and undergraduate nursing students in community health practice. We will discuss the adaptation of the Omaha System for provision of care in independent living facilities to address complex care needs. Finally, we will discuss the impact of this project and its potential for healthcare transformation in independent living facilities and transformation of education in undergraduate nursing programs.

active@home: Investigating the Value of a Home Care Worker–Led Exercise Program for Older Adults With Complex Care Needs

2019 ◽  
Vol 27 (2) ◽  
pp. 284-289 ◽  
Author(s):  
Tim Henwood ◽  
Sharon Hetherington ◽  
Madeleine Purss ◽  
Kevin Rouse ◽  
Julie Morrow ◽  
...  
Keyword(s):  
Older Adults ◽  
Home Care ◽  
Exercise Program ◽  
Complex Care ◽  
Care Needs ◽  
Home Care Worker ◽  
Complex Care Needs ◽  
Care Worker
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