Comprehensive Care Transition: A Trial of an Enhanced Care Transition Process in Dementia

Study Overview
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Brief Summary
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This pilot study examines the impact of an enhanced care transition process vs. usual care for persons with dementia admitted to a transitional unit (hospital or LTC) for management of behavioural and psychological symptoms of dementia (BPSD) with a planned discharge to long term care (LTC) facilities or other hospital units. Deficiencies in discharge processes can contribute to poor outcomes (e.g., readmissions), and there is a dearth of research on how to improve care transitions for persons with BPSD. The investigators aim to improve the care transition process for persons with dementia and BPSD utilizing an enhanced care transition process that will contain up to 6 elements: integrated behavioural care plans, videos, patient specific briefcase containing activities to reduce BPSD, in-person care transition meeting, in-person care demonstration (when possible), and follow up visits with a transition team. The ability to determine the effect of enhanced care transitions on the clinical course of patients with planned discharge to LTC or hospital may allow for improved outcomes and an overall increased efficiency of post discharge care.

Detailed Description
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The investigators have formulated an enhanced care transition process based on factors that have been documented to support care transitions in other clinical populations (e.g., Coleman, 2003 on persons with continuous complex needs; Viggiano, et al., 2012 on persons with mental health issues), along with novel package elements based on the investigators' experience working with persons with dementia and BPSD. The investigators propose to conduct a preliminary analysis of patient and staff outcomes comparing an enhanced care transition process with a control group receiving usual care. The investigators' proposed enhanced care transition process will contain 5 elements: 1. Unified transfer care document adapted to the post-care transition location 2. Videos of BPSD management to better communicate care provision, 3. Provision to -the post-care transition location a patient specific briefcase containing activities that help to reduce BPSD, 4. In-person care transition meeting between sites, including the family, to transfer knowledge, 5. In person care demonstration (when possible), and 6. Follow-up visits post transition with a transition team (a service already in existence but not consistently used). The investigators hope that with improved communication, discharge locations will be better equipped to manage BPSD, and reduce the likelihood of adverse events for both patients and staff.

Official Title
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Comprehensive Care Transition: A Randomized Control Trial of an Enhanced Care Transition Process in Dementia

Conditions
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Dementia, BPSD

Intervention / Treatment
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* Behavioral: Enhanced care transition
* Behavioral: Standard care transition


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients on behavioural transitional support unit's at Baycrest (Behavioural Neurology Unit, transitional Behavioural Support Unit) who are admitted for behavioural and psychological symptoms of dementia (BPSD) Diagnosed with a degenerative dementia Over 55 years old at the time of discharge, with a planned discharge to a long-term care (LTC) facility or another hospital unit will be eligible for the study Exclusion Criteria: None

Ages Eligible for Study
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Minimum Age: 55 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Supportive Care
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Enhanced care transition<br>The enhanced care transition will offer: (1) an integrated behavioural care plan, (2) an in- person discharge meeting including family, post-care transition staff (LTC or another hospital unit) and unit staff, (3) videos of responsive behaviours and non-pharmacological interventions, (4) a briefcase of favoured activities, (5) an in-person care demonstration, and (6) involvement of a transitional care team. | Behavioral: Enhanced care transition<br>* Enhanced care transition discharge package: (1) an integrated behavioural care plan, (2) an in-person discharge meeting including family, post-care transition staff (LTC or another hospital unit) and unit staff, (3) videos of responsive behaviours and non-pharmacological interventions, (4) a briefcase of favoured activities, (5) an in-person care demonstration, and (6) involvement of a transitional care team.<br>|
| Other: Standard care transition<br>The standard care transition varies by unit, and either consists of: (1) a discipline specific care plan, (2) a phone discharge meeting between unit staff and post-care transition staff (LTC or another hospital unit) and (3) a follow-up phone call with social work OR (1) a discipline specific care plan, (2) an in-person meeting between unit staff and (family) caregivers, (3) involvement of a transitional care team, and (4) a follow-up phone call with social work. | Behavioral: Standard care transition<br>* Standard care transition discharge package: The standard care transition varies by unit, and either consists of: (1) a discipline specific care plan, (2) a phone discharge meeting between unit staff and post-care transition staff (LTC or another hospital unit) and (3) a follow-up phone call with social work OR (1) a discipline specific care plan, (2) an in-person meeting between unit staff and (family) caregivers, (3) involvement of a transitional care team, and (4) a follow-up phone call with social work.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Post-Care Transition (PCT) questionnaire | Likert scales and open-ended questions measuring change in the transitioned resident's identified behaviour(s). | Change in resident's baseline behaviour(s) at 2 and 4 weeks | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Social work assessment questionnaire | Likert scales and open-ended questions evaluating the transition process and the post-care transition location. | At 6 months after baseline | 
| Substitute Decision Maker (SDM) satisfaction questionnaire | Likert scales and open-ended questions measuring the SDM's satisfaction with resident's transition. | At baseline | 
| Substitute Decision Maker (SDM) satisfaction questionnaire | Likert scales and open-ended questions measuring the SDM's satisfaction with resident's transition. | Change from baseline at 2 weeks | 
| Substitute Decision Maker (SDM) questionnaire | Likert scales and open-ended questions measuring the SDM's perception of the resident's identified baseline behaviour(s). | At baseline | 
| Substitute Decision Maker (SDM) questionnaire | Likert scales and open-ended questions measuring the SDM's perception of change in the transitioned resident's identified behaviour(s). | Change in resident's baseline behaviour(s) at 2 and 4 weeks | 
| Post-Care Transition (PCT) questionnaire | Likert scales and open-ended questions measuring change in the transitioned resident's identified behaviour(s). | Change in resident's baseline behaviour(s) at 3 and 6 months | 
| Post-Care Transition (PCT) staff satisfaction questionnaire | Likert scales and open-ended questions evaluating staff satisfaction with the resident's transition process. | Change from baseline at 2 and 4 weeks | 
| Chart review | Resident's additional dependent data collection (e.g., demographics, identified behaviours, Cohen Mansfield Agitation Inventory score, etc.) | At baseline | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Care transition, Behavioural and psychological symptoms of dementia, BPSD, Dementia, Persons with dementia, Discharge processes