Emergencies, Frailty, Health Care Utilization, Transition
Conditions
Keywords
Emergency Department, Care Transition, Elderly Frailty
Brief summary
Inspired by the Acute Care for Elders program at Mount Sinai Hospital, this study aims to improve care for elderly patients in four hospitals of Chaudière-Appalaches. Focusing on improving transitions between hospital and the community, this project will help professionals to adapt best practices to local context in transition of care for the elderly.
Detailed description
Background: Elderly patients discharged from hospital currently experience fragmented care, repeated and lengthy emergency department (ED) visits, relapse into their earlier condition, and rapid cognitive and functional decline. The Acute Care for Elders (ACE) program at Mount Sinai Hospital uses innovative strategies such as transition coaches, follow-up calls and patient self-care guides to improve the care transition experiences of the frail elderly patients from hospitals to the community. The ACE program reduced lengths of hospital stay and readmissions for elderly patients, increased patient satisfaction, and saved the healthcare system over $6 million in 2014. In 2016, the ACE program was implemented at one hospital in the Centre intégré en santé et en services sociaux de Chaudière-Appalaches (CISSS CA), a large integrated healthcare organization in Quebec, with a focus on improving transitions between hospital and the community for the elderly. This project used rapid, iterative user-centered design prototyping and a Wiki-suite (a free online database containing evidence-based knowledge tools in all areas of healthcare and an accompanying training course) to engage multiple stakeholders including a patient partner to improve care for elderly patients. Within this one year project, the investigators developed a context-adapted ACE intervention with the support of the Mt. Sinai Hospital, the Canadian Foundation for Healthcare Improvement and the Canadian Frailty Network. The goal is to scale up the ACE program for elderly care transition to three new hospital sites within the CISSS CA, using the Wiki-suite to allow for further context-adaptation of the program in these new hospitals. Objectives: 1) Implement a context-adapted ACE program in three hospitals in the CISSS CA and measure its impact on patient, caregiver, clinical and hospital-level outcomes; 2) Identify underlying mechanisms by which the context-adapted ACE program improves care transitions for the elderly; 3) Identify underlying mechanisms by which the Wiki-suite contributes to context-adaptation and local uptake of knowledge tools. Methods: Objective 1: Staggered implementation of the ACE program across the three CISSS CA sites; interrupted time series to measure the impact on hospital-level outcomes; pre/post cohort study to measure the impact of the new program on patient, caregiver and clinical outcomes. Objectives 2 and 3: Parallel mixed-methods process evaluation study to understand the mechanisms by which the context-adapted ACE program improves care transitions for the elderly and by which the Wiki-suite contributes to adaptation, implementation and scaling up of geriatric knowledge tools. Expected results: This project will provide much needed evidence on effective Knowledge Translation (KT) strategies to adapt best practices to local context in transition of care for the elderly. It will contribute to adapting geriatric knowledge to local contexts. The knowledge generated through this project will support future scale-up of the ACE program and the wiki methodology to other settings in Canada.
Interventions
BEHAVIORALGEM nurse
hospital-based geriatric emergency nurse (GEM nurse) specialist to support patients during the post-discharge transition period
BEHAVIORALpre- and post-hospitalization medication list reconciliation
pre- and post-hospitalization medication list reconciliation for elderly
BEHAVIORALsystematic discharge summaries
systematic discharge summaries given to patients and/or caregiver, and sent to their family physician
BEHAVIORALmedical follow-up appointment
a planned follow-up appointment with their family physician
BEHAVIORALfollow-up phone call
a systematic follow-up phone call for discharged patients
OTHERWiki-based Knowledge tools
access to wiki-based patient-oriented KT tools
access to a community-based telemonitoring service
Sponsors
Laval University
Study design
Allocation
NON_RANDOMIZED
Intervention model
SEQUENTIAL
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
65 Years to No maximum
Healthy volunteers
No
Inclusion criteria
Eligible patients will be: * aged ≥ 65 years * be discharged from the ED * able to understand and read French * able to give informed consent Eligible caregivers will be: * identified by the patients themselves * able to understand and read French * able to give informed consent
Exclusion criteria
\-
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Change of 30-day hospital readmission | each month during 4 years (48) | Composite endpoint at each month 30-day hospital readmission |
| Change of 30-day ED visit rate | each month during 4 years (48) | Composite endpoint at each month 30-day ED visit rate |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| 3- Change Alternate level care occupation rate- Hospital-level outcome | Each month during 4 years (48) | Hospital administrative databases (e.g., MedGPS, Logibec, Montreal, Canada) will be used to calculate monthly hospital-level outcomes. Monthly data will then be analyzed to form points in time. Data from the Régie d'assurance maladie du Québec (RAMQ) physician billing database and MedECHO database (containing data on hospitalizations and health professional consultations for all institutions) will also be extracted in addition to databases available at the Institut national d'excellence en santé et services sociaux (INESSS) in order to identify all health services used prior to and after the implementation of the ACE intervention. 3) Alternate level care occupation rate |
| 4- Change Rate of patients returning to pre-hospital living situation- Hospital-level outcome | Each month during 4 years (48) | Hospital administrative databases (e.g., MedGPS, Logibec, Montreal, Canada) will be used to calculate monthly hospital-level outcomes. Monthly data will then be analyzed to form points in time. Data from the Régie d'assurance maladie du Québec (RAMQ) physician billing database and MedECHO database (containing data on hospitalizations and health professional consultations for all institutions) will also be extracted in addition to databases available at the Institut national d'excellence en santé et services sociaux (INESSS) in order to identify all health services used prior to and after the implementation of the ACE intervention. 4) Rate of patients returning to pre-hospital living situation |
| Clinicians and decision maker outcomes (Qualitative outcome) | each 3 months, during 4 years (12) | Individual interviews will be performed every 3 months after the beginning of the implementation of the Acute Care for Elders (ACE) program at each hospital among health professionals and decision makers participating in the ACE program. These semi-structured interviews will be based on the National Health Services (NHS) Sustainability Model. This qualitative questionnaire will serve to identify the contextual elements that influenced the successful (or failed) implementation of the (Approche adaptée à la personne âgée) AAPA / ACE program for improving care transitions. These interviews will be conducted by doctoral and/or Master students, guided by experienced qualitative researcher |
| 1- Care Transitions Measure (CTM3) - Patient outcome | 48-72 hours post-discharge for 3-item Care Transitions Measure (CTM3) | The 3-item Care Transitions Measure (CTM-3) is a 3-item questionnaire measuring the perceived quality of the transition care on a 0-3 scale (0 = fully disagree; 4 = fully agree). Mean of the 3 items are linearized to obtain 0-100 scoring scale. |
| 2- GAI-SC-SF - Patient outcome | within 7 days after post-discharge | The Geriatric Anxiety Inventory-short form (GAI-SF) has been specifically developed to measure anxiety among seniors and it has good psychometric values. The short version comprises five questions.Each positive item/question = 1. Score range 0 to 5. Anxiety is detected 3 out of 5 and above. |
| 3- Living situation - Patient outcome | 30 days post-discharge | Living situation will be collected in the medical file when available at 30 days post-discharge. |
| 1- change Hospital/ED length of stay - Hospital-level outcome | Each month during 4 years (48) | Hospital administrative databases (e.g., MedGPS, Logibec, Montreal, Canada) will be used to calculate monthly hospital-level outcomes. Monthly data will then be analyzed to form points in time. Data from the Régie d'assurance maladie du Québec (RAMQ) physician billing database and MedECHO database (containing data on hospitalizations and health professional consultations for all institutions) will also be extracted in addition to databases available at the Institut national d'excellence en santé et services sociaux (INESSS) in order to identify all health services used prior to and after the implementation of the ACE intervention. 1) Hospital/ED length of stay |
| Caregiver-level outcomes | 7days patient post-discharge | The Zarit Burden Interview (ZBI) is one of the most used tools for measuring the burden of caregivers. The brief French version (12 questions) of the scale has good psychometric properties, comparable to the original version.For each question, range answer is : Never=0, Rarely= 1, Sometimes= 2, Quite frequently=3, Nearly always=4. Summation of 12 items 0 to 4 points per item range 0 to 48 as total score. Score between 0-10 = no to mild burden; score between 10-20 = mild to moderate burden; score \>20 = high burden.This tool is already used by CISSS-CA staff. Mentioned in Quebec's Alzheimer's Plan\[89\], caregiver burden increases as the disease progresses and is associated with psychological distress and physical health problems. Caregivers are therefore a risk group within the health system. |
| 1-Clinical-level process outcome - Proportion of patients assigned a GEM Nurse | Process assessment with a monthly Chart audit for 4 years | Proportion of patients assigned a GEM Nurse |
| 2-Clinical-level process outcome - Proportion of patients/caregiver/physician receiving discharge summary | 48 hours post-discharge questionnaire and family physician follow-up phone call | Proportion of patients/caregiver/physician receiving discharge summary |
| 3-Clinical-level process outcome - Proportion of medication list reconciliation | monthly Chart audit for 4 years | Proportion of medication list reconciliation |
| 4-Clinical-level process outcome - Proportion of patients with physician appointment | Family physician follow-up phone call post-discharge up to 30 days | Proportion of patients with physician appointment |
| 5-Clinical-level process outcome - Proportion of patients using telemonitoring | monthly Chart audit for 4 years | Proportion of patients using telemonitoring using Télé-Surveillance Santé Chaudieres-Appalaches (TSS-CA) database |
| 4- baseline sociodemographic data - Patient outcome | within 7 days after post-discharge | baseline sociodemographic data (age, sex, race, language, education level, family income will be collected. |
| 2- change ED admission rate - Hospital-level outcome | Each month during 4 years (48) | Hospital administrative databases (e.g., MedGPS, Logibec, Montreal, Canada) will be used to calculate monthly hospital-level outcomes. Monthly data will then be analyzed to form points in time. Data from the Régie d'assurance maladie du Québec (RAMQ) physician billing database and MedECHO database (containing data on hospitalizations and health professional consultations for all institutions) will also be extracted in addition to databases available at the Institut national d'excellence en santé et services sociaux (INESSS) in order to identify all health services used prior to and after the implementation of the ACE intervention. 2) ED admission rate |
Countries
Canada
Contacts
Primary ContactPatrick M Archambault, MD, MSc
Backup ContactPascal Y Smith, PhD
Outcome results
None listed