scholarly journals An integrated hospital-to-home transitional care intervention for older adults with multimorbidity and depressive symptoms: A pragmatic effectiveness-implementation trial

2021 ◽  
Vol 21 (S1) ◽  
pp. 134
Author(s):  
Rebecca Ganann
Keyword(s):  
Older Adults ◽  
Depressive Symptoms ◽  
Transitional Care ◽  
Care Intervention ◽  
Hospital To Home ◽  
Implementation Trial

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.

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 AN INTEGRATED TRANSITIONAL CARE MODEL FOR OLDER ADULTS WITH MULTIMORBIDITY AND DEPRESSIVE SYMPTOMS

2019 ◽  
Vol 3 (Supplement_1) ◽  
pp. S867-S867
Author(s):  
Maureen Markle-Reid ◽  
Carrie McAiney ◽  
Rebecca Ganann ◽  
Kathryn Fisher ◽  
Amy Bartholomew ◽  
...  
Keyword(s):  
Social Support ◽  
Older Adults ◽  
Depressive Symptoms ◽  
Physical Functioning ◽  
Chronic Conditions ◽  
Service Use ◽  
Transitional Care ◽  
Group Differences ◽  
Significant Group ◽  
Implementation Effectiveness

Abstract This pragmatic randomized controlled trial examined the implementation, effectiveness and costs of a nurse-led transitional care intervention to improve hospital-to-home transitions for 127 older adults (≥ 65 years) with depressive symptoms and multimorbidity in three Ontario communities. Participants were randomly allocated to receive the intervention plus usual care (n=63) or usual care alone (n=64). The intervention included an average of 5 in-home visits and 6 phone calls from a Registered Nurse (RN) over a 6-month period. The RN provided system navigation, patient education, medication review, and management of depressive symptoms and chronic conditions. Implementation outcomes included engagement rate, intervention dose, and feasibility of intervention implementation. Effectiveness outcomes included quality of life, depressive symptoms, anxiety, social support, and health and social service use and costs. Participants were an average of 76 years and had an average of 8 chronic conditions. Findings suggest that the intervention was feasible and acceptable to participants and providers. Intention-to-treat analyses using ANCOVA models showed no statistically significant group differences for the outcomes. However, the upper 95% confidence interval for the mean group difference showed greater clinically significant improvements in physical functioning in the intervention group. Quantile regression showed that the intervention may result in greater improvements in physical functioning for individuals with low to average physical functioning values compared to the control group. The intervention may also result in higher levels of perceived social support for individuals with a range of social support values. No statistically significant group differences were observed for service use or costs.

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

Does an Outreaching Stepped Care Program Reduce Depressive Symptoms in Community-Dwelling Older Adults? A Randomized Implementation Trial

2015 ◽  
Vol 23 (8) ◽  
pp. 807-817 ◽  
Author(s):  
Ilse M.J. van Beljouw ◽  
Eric van Exel ◽  
Peter M. van de Ven ◽  
Karlijn J. Joling ◽  
Ton D.F. Dhondt ◽  
...  
Keyword(s):  
Older Adults ◽  
Depressive Symptoms ◽  
Care Program ◽  
Community Dwelling ◽  
Stepped Care ◽  
Community Dwelling Older Adults ◽  
Implementation Trial

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.

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