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Research Spotlight: Hospital-to-home transitional care for seniors

Nov 23, 2016
Guylaine Spencer

Getting released from a hospital sounds like good news, but if you’re older and have multiple chronic conditions and possibly symptoms of depression, it can be very risky.

“One of the big problems that people find is that when they get home, they are overwhelmed because of the complexity involved in managing their multiple conditions and their medications, recommendations, and needs associated with them”, says McMaster School of Nursing professor Dr. Maureen Markle-Reid.  Along with Dr. Carrie McAiney, Markle-Reid is co-leading a research study that will design and test a new “hospital-to-home transitional care” program.

What is the study about?

The study, which is funded by a $1 million Ontario SPOR Support Unit IMPACT award for Home and Community Care, began in April 2016. Researchers plan to complete it by September 2019. Despite the high prevalence of depressive symptoms in older adults with multiple chronic conditions, depression screening is not always a part of usual practice. The program will screen older adults for depressive symptoms prior to discharge from hospital. Older adults who screen positive for depressive symptoms will be invited to take part in the study. “How the nurse-led intervention is implemented and adapted will be determined together with the participating sites  says Markle-Reid. “Intervention components are likely to include nurses who will visit patients in their homes and work with others in the community to get patients the support they need – whether that is home care, meals on wheels, or transportation to their doctors.”

The program is six months in duration.  Markle-Reid notes that “the frequency and timing of the visits will be tailored according to the patient’s needs and preferences. We’d like the nurse to go in fairly soon after discharge, but then the interval for the next visit will depend on the outcome of the assessment and the needs and preferences of the individual. So it’s very patient-focussed and client-centred, as opposed to disease-centred. There’s a big focus on not just addressing depressive symptoms, which is a huge issue unto its own, but all of the other co-morbidities that person has.” Nurses will speak with the patient about any concerns the patient may have about their nutrition, exercise, social and financial supports, etc. “We hope the nurse can help identify some of those issues and link people to the appropriate services,” says Markle-Reid. “It’s not just about depressive symptoms. It’s about the whole person.” The emphasis is on prevention and health promotion.

Who is involved?

The study will involve 216 older adults. It is led by Maureen Markle-Reid, co-scientific director of the ACHRU and Canada Research Chair in Aging, Chronic Disease and Health Promotion Interventions, and Dr. Carrie McAiney, Associate Professor in the Department of Psychiatry and Behavioural Neurosciences and Graduate Faculty Member in the School of Nursing at McMaster University. There are also 15 co-investigators, a study co-ordinator and study trainees. Family doctors, hospitals, Community Care Access Centres (CCAC), other seniors mental health and community support services, as well as Local Health Integration Networks (LHINs), are involved.

A complex process

The program will be tested in Sudbury, Burlington, and Hamilton. “We have held community forums in each region to find out what is happening in the area of transitional care for this population,” says Markle-Reid.  “What do they see as the gaps, what kinds of strategies are already being implemented? And who might be interested in being part of the study?” Patients and their families, as well as health care and social services, will be involved in all aspects, including implementing and testing the intervention, adapting it to local settings, and serving on the advisory committees.

“Engaging with the community is critically important in today’s research,” says Markle-Reid.  First, you need to listen to patients and caregivers to ensure that what you’re doing is meaningful to them. Second, you need to “engage with the community and find out what their needs are, because those interventions will never be sustained and taken up if you don’t build relationships with those communities to begin with,” she explains.

Adapting the program to the local community is key to its implementation and sustainability. “We might build it one way in Burlington, and build it another way in a small rural community because they don’t have the same resources. One aspect may be important to one community and another aspect somewhere else.”

Researchers expect the program to pay for itself. Even though it will cost a bit more to have a nurse do all these things, the cost will be reduced elsewhere, i.e. in the reduction in emergency room visits or readmission rates.

What happens when the study ends?

Markle-Reid notes the ultimate goal is for the program to be scaled up and spread to other regions in Ontario. “We are hoping to build capacity to enable the intervention to continue beyond the life of the research.”

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