Clinical trial NCT04093245: The LEARNING WISDOM Phase II Scale up Project
Official title: Supporting the Creation of a LEARNing INteGrated Health System to Mobilize Context-adapted Knowledge With a Wiki Platform to Improve the Transitions of Frail Seniors From From Hospitals and Emergency Departments to the cOMmunity: Phase II
Study type: INTERVENTIONAL
Overall status: UNKNOWN
Phase: NA
Conditions: Transition
Emergencies
Health Care Utilization
Frailty
Keywords: Emergency Department
Care Transition
Elderly Frailty
Lead sponsor: Laval University
Sponsor class: OTHER
First posted: 2019-09-17
Enrollment: 4000
Sex: ALL
Minimum age (years): 65
Standard ages: OLDER_ADULT
Accepts healthy volunteers: no
Allocation: NON_RANDOMIZED
Intervention model: SEQUENTIAL
Primary purpose: HEALTH_SERVICES_RESEARCH

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.

Eligibility criteria: 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:

-

Primary outcomes:
measure: Change of 30-day hospital readmission
timeFrame: each month during 4 years (48)
measure: Change of 30-day ED visit rate
timeFrame: each month during 4 years (48)
Secondary outcomes:
measure: 1- change Hospital/ED length of stay - Hospital-level outcome
timeFrame: Each month during 4 years (48)
measure: 2- change ED admission rate - Hospital-level outcome
timeFrame: Each month during 4 years (48)
measure: 3- Change Alternate level care occupation rate- Hospital-level outcome
timeFrame: Each month during 4 years (48)
measure: 4- Change Rate of patients returning to pre-hospital living situation- Hospital-level outcome
timeFrame: Each month during 4 years (48)
measure: Clinicians and decision maker outcomes (Qualitative outcome)
timeFrame: each 3 months, during 4 years (12)
measure: 1- Care Transitions Measure (CTM3) - Patient outcome
timeFrame: 48-72 hours post-discharge for 3-item Care Transitions Measure (CTM3)
measure: 2- GAI-SC-SF - Patient outcome
timeFrame: within 7 days after post-discharge
measure: 3- Living situation - Patient outcome
timeFrame: 30 days post-discharge
measure: 4- baseline sociodemographic data - Patient outcome
timeFrame: within 7 days after post-discharge
measure: Caregiver-level outcomes
timeFrame: 7days patient post-discharge
measure: 1-Clinical-level process outcome - Proportion of patients assigned a GEM Nurse
timeFrame: Process assessment with a monthly Chart audit for 4 years
measure: 2-Clinical-level process outcome - Proportion of patients/caregiver/physician receiving discharge summary
timeFrame: 48 hours post-discharge questionnaire and family physician follow-up phone call
measure: 3-Clinical-level process outcome - Proportion of medication list reconciliation
timeFrame: monthly Chart audit for 4 years
measure: 4-Clinical-level process outcome - Proportion of patients with physician appointment
timeFrame: Family physician follow-up phone call post-discharge up to 30 days
measure: 5-Clinical-level process outcome - Proportion of patients using telemonitoring
timeFrame: monthly Chart audit for 4 years
Other outcomes:
Locations:
city: Lévis
country: Canada
facility: Centres intégrés de santé et de services sociaux (CISSS) De Chaudières-Appalaches
state: Quebec
Study officials:
affiliation: Laval University
name: Patrick M Archambault, MD, MSc
role: PRINCIPAL_INVESTIGATOR
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