Systems Addressing Frail Elders (SAFE) Care Implementation
Condition: Frail Older Adutls
Study type: Observational

Summary: 
      Systems Addressing Frail Elders (SAFE) Care is a nurse-led interprofessional team model to
      rapidly identify and provide safe and effective inpatient care to high risk older adults and
      help support their successful transition back to the community. Developed and demonstrated to
      be effective in one hospital - the model is now being disseminated and studied in three
      additional hospitals (multiple organizational case study).
    

Detailed description: 
      Three Magnet hospitals in Los Angeles County (Huntington Hospital, Torrance Memorial Medical
      Center and Ronald Reagan UCLA Health System) are collaborating on this demonstration and
      evaluation project (Multiple Case-Study Design). The project will engage interprofessional
      hospital leadership; provide training and coaching in implementation processes of the SAFE
      Care model; and track outcome of the SAFE Care model as implemented in the three
      collaborating site hospitals (three case studies). The investigators hope to contribute to
      the existing state of the science in dissemination and implementation of evidenced-based
      innovations. The collective data from the three sites (collected through interviews with
      hospital leadership and staff and with de-identified patient data on program implementation
      outcomes) will provide information about the effectiveness of the implementation process and
      support further dissemination.
    

Intervention name(s): SAFE Care model of care
Intervention type(s): Other
Intervention description(s): SAFE Care Model Site Intervention:
Endorse best practices for frail patients;
Identify frail patients promptly using multi-dimensional screening and assessments;
Employ interprofessional unit-based care team approach to frailty risk reduction during inpatient stay and create post-acute care transitions (PACT) plan recommendations;
Develop electronic health record templates for patient-centered interprofessional frailty notes;
Communicate PACT plans to primary care providers to promote safe transitions to the ambulatory setting and across the continuum of care.
Increase awareness, improve management of frailty, and improve overall health and well-being for adults who are frail or at risk of becoming frail.
Observational model: Other
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        This project does not have a set recruitment/enrollment goal. Process evaluation
        information will be collected by interview and observation of leadership and staff at three
        implementation sites. Quality Improvement (QI) outcome data will be collected involving
        elderly patients (> 65 years) admitted to two med-surg units at each of the three
        collaborating sites over designated time periods: One month prior to implementation and six
        month after intervention. QI data from each hospital will be de-identified and submitted to
        core research team for analysis of patient outcomes.
      
Keywords: Frail Older Adults, Interprofessional Team