None listed
Conditions
Brief summary
People coming into the Transition Care Program (TCP) are invited to participate in a research project. In collaboration with Metro South Health in Queensland, and the University of Queensland, we are conducting a study to understand goals, activity patterns and other health data relevant to older people who enter the TCP following their stay in hospital. We will use Fitbits to collect activity and health data. You will also be asked to do some additional health assessments when you first start TCP and when you exit TCP. The purpose of this study is to examine how much TCP clients’ move around each day and to see how this is related to their goals, health and quality of life outcomes throughout the program. Future benefits for TCP clients’ may include improved clinical monitoring and patient care, as well as better goal attainment and health outcomes.
Interventions
Transition Care Program (TCP) staff who are predominantly nursing or allied health professionals will deliver this intervention. 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. The program is goal-oriented, although goal-setting training is o
Transition Care Program (TCP) staff who are predominantly nursing or allied health professionals will deliver this intervention. 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. The program is goal-oriented, although goal-setting training is often on-the-job and not standardised. Other behavioural tools are also not routinely integrated as standard practice. For TCP sites that are allocated to the intervention group, staff will receive a specially designed goal-setting and behaviour change training workshop. This workshop has been co-designed with previous TCP staff members and will be delivered by project researchers, including a behavioural scientist and geriatrician. Using information learned, staff will support clients in their goal-setting and goal-attainment using a structured person-centred, motivation approach and behaviour change techniques. TCP staff are allied health professionals with existing undergraduate or job-related training in goal setting. The upskilling training session will be delivered through a 90-120 minute face-to-face or video 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. Staff will be trained to use the Health Action Process 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. In addition to the live workshop, TCP staff will also receive a video recording of the training and a written guide specifically designed for this study. Staff will use these strategies each time they visit participants, in-person in the clients’ home or via telephone. This is most often weekly. 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 (TCP clients) 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. Fidelity of the intervention will be assessed using these goal-setting case report forms, as well as a review with the study's behavioural scientist for each TCP staff member actively involved in the research.
Sponsors
Metro South Health
Study design
Allocation
Randomised controlled trial
Intervention model
Parallel
Primary purpose
Educational / counselling / training
Masking
Open (masking not used)
Eligibility
Sex/Gender
All
Age
65 Years to No maximum
Healthy volunteers
No
Inclusion criteria
For inclusion, potential TCP Sites will be: • Willing to participate • Have staff available to complete the behaviour change training • Provide written agreement by the service manager to participate For inclusion, potential clients will be: • Enrolled in TCP • Understand the research project and have the ability to sign the consent form
Exclusion criteria
The following will render a site ineligible: • Behaviour change training received in last 6 months • Case manager’s/clinicians’ unwillingness to train The following will render a potential participant ineligible: • Being wheelchair-bound • Severe dementia or other cognitive impairment that prevents the client from participating in the study • Admitted to residential TCP • At the discretion of staff/managers due to any potential safety issues
Outcome results
None listed