Feasibility and acceptability of a transitional care intervention for frail older adults returning home from hospital: The TRANSFER-II Study

The TRANSFER-II Study will include the provision of patient centred discharge communication when leaving hospital. Once the participant is recruited, consented and the baseline assessments completed, the intervention commences. The intervention is in addition to standard clinical practice and usual patient care will continue. The Nurse Navigator (intervention nurse) will meet with the patient in hospital before discharge and discuss the plan for home and make any appropriate referrals. At this time the Nurse Navigator will identify 3 patient-centred priorities for home as derived by the discharge summary Plan/Recommendation of care and medical team. These will be determined through discussion with the patient around what is important to them from the list of activities written on the discharge summary plan and then prioritised in a list of 1 to 3 in consultation with the Nurse Navigator. Once discharged, the Nurse Navigator will contact the patient within one week and then again the following week to provide support and answer questions about the discharge summary and follow up plan, and discuss progress of the 3 patient-centred priorities. During this contact the nurse will make any appropriate referrals, facilitate GP review where needed, provide virtual education and resources as necessary. The intervention is as follows: • Contact during admission (initial 30 minute consultation) by the Nurse Navigator and discuss with the patient the plan for discharge. Provide the patient the ‘Nurse Navigator Flyer’ (designed by the research team for this study). • Medical staff complete the discharge summary as usual routine practice. • Nurse Navigator sets three patient-centred priorities with the patient from the discharge summary plan/recommendations of care, three things to do when the patient returns home, these will be discussed verbally and written down in simple language on the ‘Plan for Home’ sheet (designed by the research team for this study). This may have to be completed over the phone if patient is discharged afterhours or non-working days of the intervention nurse and posted if this is requested by participant (approximately 15-30 minutes). • The nurse will help to organise and facilitate these patient-centred priorities prior to discharge. At this time, will also help to identify any unmet needs and ensure safety on discharge. • The nurse will then follow up with a telehealth contact (using a hospital landline) within 1 week of discharge to discuss these 3 patient-centred priorities, then again the following week with a total of 2 points of contact within the intervention. These telehealth contacts will approximately be 30 minutes in duration, and on average 1 week apart. • Provide support and answer questions about the discharge summary and follow up requirements. Ensuring there is clear communication to the patient about the discharge plan in language that they will understand. During these contacts the intervention nurse will help to facilitate further community support where possible, e.g. organise GP/clinician review or referral to CareFinder. • These intervention calls may generate additional calls within these points of contact to organise follow up or update the participant with appointment details. For example the participant states they were unable to call their GP for follow up, the intervention nurse calls the GP and books this appointment, then calls the participant back to update appointment time and details. This would be considered one point of contact. Every participant will receive a minimum of 2 contacts approximately 1 week apart, • These calls and any additional will be tracked and documented within study feasibility data collection through REDCap. Study adherence will also be tracked through REDCap data collection on patients' ability to set and achieve priorities and, through Electronic Medical Records documentation. All included participants will receive usual care as well as the intervention. Standard practice for discharge is that all patients are assessed during admission for issues returning home and referred to relevant services (e.g. Hospital in the Home) where appropriate. All patients on discharge are given a Discharge Summary as written by the medical team. Currently there is no patient-centred discharge communication or post-discharge follow-up of this nature that exists within the hospital.