Physical activity, goals and outcomes for older Australians in the Transition Care Program: a pragmatic randomised controlled trial

Transition Care Program (TCP) case managers will deliver this intervention. Case managers are predominantly nursing or allied health professionals who take on additional responsibilities coordinating the care of older adults in the TCP. In TCP, usual care involves the coordination of slow-stream rehabilitation for older adults following a hospital stay. Rehabilitation services can include Physiotherapy, Occupational Therapy, Nursing, social care, support workers, and community transportation, tailored to the unique needs of each client. In the relevant sites, goal setting is part of standard care, although the type of goals is not pre-specified. Case managers will guide clients in the intervention group to set and achieve community-based goals specifically, using a structured person-centred, motivation approach and behaviour change techniques. We hypothesise that participating in community-based activities, participants will increase their incidental and light-itensity activities. Case managers and other team members will be trained to use the Health Action Planning Approach (HAPA) method of behaviour change in conjunction with Social Cognitive Theory constructs of self-efficacy, social support, and outcome expectancies. Strategies will include education on perceived risks, outcome expectations, goal setting, self-monitoring, and motivational interviewing. Case managers will use these strategies each time they visit participants, usually once weekly for up to an hour, in-person in the clients’ home or via telephone. Family members can be present and involved as per usual practice. Most TCP clients stay in the program for 8 weeks, although up to 12 weeks is possible. Participants will receive access to client materials to help them set and achieve their goals, mapped to the HAPA model. Resources available are both pre-existing (https://clinicalexcellence.qld.gov.au/sites/default/files/2019-04/goal-setting-workbook.pdf) and specifically designed for this study. Case managers will collect and record in electronic format information on client goals, including goal types, behaviour change strategies used, and whether goals are achieved. Case managers and staff in TCP are allied health professionals with existing undergraduate or job-related training in goal setting. The upskilling training session with be delivered through a 90-minute face-to-face session on the theoretical background to behaviour change, as well as an applied portion with two case-studies. The session will be delivered at least one week prior to participant recruitment by members of the research team skills in behaviour change, goal setting, and geriatric medicine.