Clinical trial NCT02415504: Comprehensive Care Transition: A Trial of an Enhanced Care Transition Process in Dementia
Official title: Comprehensive Care Transition: A Randomized Control Trial of an Enhanced Care Transition Process in Dementia
Study type: INTERVENTIONAL
Overall status: TERMINATED
Phase: NA
Conditions: Dementia
BPSD
Keywords: Care transition
Behavioural and psychological symptoms of dementia
BPSD
Dementia
Persons with dementia
Discharge processes
Lead sponsor: Baycrest
Sponsor class: OTHER
Collaborators: name: Ontario Ministry of Health and Long Term Care
First posted: 2015-04-14
Enrollment: 29
Sex: ALL
Minimum age (years): 55
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: SUPPORTIVE_CARE

Brief summary: 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: 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.

Eligibility criteria: 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

Primary outcomes:
measure: Post-Care Transition (PCT) questionnaire
timeFrame: Change in resident's baseline behaviour(s) at 2 and 4 weeks
Secondary outcomes:
measure: Social work assessment questionnaire
timeFrame: At 6 months after baseline
measure: Substitute Decision Maker (SDM) satisfaction questionnaire
timeFrame: At baseline
measure: Substitute Decision Maker (SDM) satisfaction questionnaire
timeFrame: Change from baseline at 2 weeks
measure: Substitute Decision Maker (SDM) questionnaire
timeFrame: At baseline
measure: Substitute Decision Maker (SDM) questionnaire
timeFrame: Change in resident's baseline behaviour(s) at 2 and 4 weeks
measure: Post-Care Transition (PCT) questionnaire
timeFrame: Change in resident's baseline behaviour(s) at 3 and 6 months
measure: Post-Care Transition (PCT) staff satisfaction questionnaire
timeFrame: Change from baseline at 2 and 4 weeks
measure: Chart review
timeFrame: At baseline
Other outcomes:
Locations:
city: Toronto
country: Canada
facility: Baycrest
state: Ontario
Study officials:
affiliation: Neuropsychology and Cognitive Health at Baycrest
name: Colleen Ray, PhD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Viggiano T, Pincus HA, Crystal S. Care transition interventions in mental health. Curr Opin Psychiatry. 2012 Nov;25(6):551-8. doi: 10.1097/YCO.0b013e328358df75.
citation: Coleman EA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc. 2003 Apr;51(4):549-55. doi: 10.1046/j.1532-5415.2003.51185.x.