Testing the feasibility of Living Well after Hospital: A coordinated care program for older adults returning home after hospital

The evidence-based, co-designed Living Well after Hospital program consists of four components curated to provide synergistic support to patient and support person dyads (herein referred to as 'dyads') in the transition from hospital to home, delivered over a 60-day period following discharge from the primary admission. Components were identified through a literature review and further developed in collaboration with a dedicated Intervention Working Group comprising clinical and research experts. Dyads from the John Hunter Hospital convened over two co-design workshops to further refine the program. Relevant healthcare professionals were consulted to sense-check its real-world integration. Component 1: Assigning a dedicated Living Well nurse (Clinical Nurse Specialist Level 1) to each older adult to provide care coordination and routine follow-up. The Living Well nurse will arrange a 30-45 minute face to face meeting with dyads on the ward within 48 hours of expected discharge to: (i) provide an overview of their role as the primary point of contact and coordinator of the Living Well program for the first 60 days after discharge; (ii) ask the dyad about their needs when they return home across a comprehensive range of domains, including medications, nutrition, follow-up appointments, physical activity and falls prevention, accessing aged care services, mental health, social connections, advance care planning, cognition, and healthy behaviours; (iii) develop mutually agreed goal(s) for the patient to work towards, (iv) develop a personalised Action Plan (Component 2) for the dyad to follow when they return home, (v) provide the support person with information and guidance to enhance adherence to the Action Plan. Routine follow-up: The Living Well nurse will also conduct up to 30 minute telephone or video-calls with the dyad (according to their preference) at one-, three- and eight-weeks following discharge to assess and encourage use of their Action Plan, explore any challenges to completing recommended actions, progress towards reaching their agreed goal, and any changes since the Action Plan was developed. Dyads will be sent an SMS reminder two days ahead of each telephone call. Dyads will receive an SMS message at two-, four- and six-weeks following discharge reiterating the nurse’s advice. The Living Well nurse will also be available for dyads to call three days per week from 8am – 4pm to answer any questions and provide additional support as needed. Patients who are discharged to a rehabilitation facility will only receive follow-up calls once it has been confirmed that they have returned home. Component 2: Providing a structured and personalised Action Plan. The Living Well nurse will collaborate with dyads and the ward’s allied health team to develop a personalised Action Plan tailored to the individual's circumstances and needs. The Action Plan will be in addition to the discharge summary that is routinely provided to all patients as part of usual care, and aligned with the National Safety and Quality Health Service (NSQHS) Standards. It will consist of a standardised electronic template that will be tailored by the Living Well nurse according to the outcomes of their meeting with the dyad. The Action Plan will include the following components: (i) What should I do in the first week after returning home? Includes advice on which sections of the Action Plan and which Educational Modules to review first, attending a follow-up general practitioner (GP) appointment within 7-10 days, if they are taking 5 or more medications, asking their GP to arrange a Home Medicines Review, and to expect a follow-up telephone call from the Living Well nurse; (ii) What should I do in weeks 2-4 after returning home? Advises patients to continue reviewing Action Plan, review remaining Educational Modules, and expect another follow-up call from the Living Well nurse. (iii) My hospital stay. A brief summary of the main reason/s for admission and treatments received during the hospital stay; (iv) My Actions: A personalised list of recommended actions across the domains discussed during their meeting; (v) My Goals: A summary of the goal(s) agreed during their meeting, and steps and resources needed to achieve the goal(s); (vi) Physical activity planner, to assist patients to record the activities they complete according to their agreed exercise plan; (vii) Symptom diary which allows patients to keep a record of the type and frequency of any symptoms of concern, and take with them to medical appointments; (viii) Preparation for medical appointments, including tips for how to get the most out of appointments, and a Question Prompt List of suggested questions that can be used to guide conversations with healthcare providers during appointments; (ix) Refrigerator checklist, a brief personalised summary of actions for dyads to place somewhere they visit often (e.g. refrigerator door) as a reminder of tasks to complete. Component 3: Providing easily accessible educational modules on important topics for post-discharge care. Dyads will be provided with 9 educational modules spanning all key topics important for post-discharge care to improve adherence to recommended actions. Each modules is designed to be brief and completed within 5 minutes. Content has been reviewed by relevant health care professionals and consumers. Modules will be made available in print and video format on a dedicated password-protected Living Well website to account for differences in preferences for receiving information. Each module incorporates evidence-based communication strategies including providing simple concise instructions, chunking, repetition of important units of information, and use of visual aids. Content has a grade 6 reading level and adheres to guidelines for communication with older adults. Online modules are designed in line with the Web Content Accessibility Guidelines. Videos are presented by clinicians, members of the research team and consumers, and include closed captions. The website has the ability to adjust font size and have text read aloud. The Living Well nurse will prompt participants to complete the modules during their routine telephone calls. Component 4: Active linking and encouragement to utilise community-based health provider resources. Linkage with GPs: To link older adults with their GP, the Living Well nurse will assist with scheduling an appointment (where the patient is being transferred directly home) and provide a Transfer of Care letter and study documentation including the information sheet and the patient’s Action Plan. This documentation will be sent to the GP’s practice via email, and hard copies will also be provided to the dyad to bring with them to their follow-up appointment. Linkage with pharmacists for medication review: Where the patient is taking five or more medications, they will be encouraged to speak to their GP about being referred for a Home Medicines Review. Where the patient is taking less than five medications, but their medications have changed during their hospital stay, the Living Well nurse will request the dyad visit a pharmacist within one week of discharge. Training: Living Well nurses will be provided with an intervention manual including suggested scripts. Over 3 x 4 hours sessions conducted the week prior to recruitment, nurses will be trained to competency by a geriatrician who is a member of the research team. Training will include motivational interviewing techniques and role playing exercises. Intervention adherence/fidelity: Follow-up surveys for patients and support persons will ask: • How often they have referred to their Action Plan since discharge, and utilised resources (e.g. symptom diary, physical activity tracker, refrigerator checklist). • How many times they have read each of the Educational Modules (in print and online format). The number of log-ins to the Living Well website, number of modules accessed, time spent on each page and number of clicks on videos will be tracked using in-built monitoring software. • Whether they had been to see their GP, and if so whether they brought their Action Plan and Transfer of Care letter with them, and whether these documents were discussed. • If they were taking five or more medications, whether their GP had referred them for a Home Medicines Review. • If their medications had changed during their hospital stay, whether they had seen a community pharmacist to review these changes. For each dyad, the Living Well nurse will complete a checklist including: • The number of intervention components they delivered (either completely or in part), • The time taken to deliver each intervention component. For 20% of recruited dyads (n=8), a geriatrician who is a member of the research team will attend and observe the meeting between the Living Well nurse and the dyad. The geriatrician will use a study-specific checklist to assess whether all required meeting components are present and whether the subsequent Action Plan developed includes all required elements. Booster training will be provided where issues with protocol adherence are identified.