Older Adults With Complex Care Needs Clinical Trial
— DBOfficial title:
Digital Bridge: Using Technology to Support Patient-centered Care Transitions From Hospital to Home
Older adults who live with multiple chronic conditions are more likely to experience frequent admissions and discharges from hospital. These transitions are often challenging and leave people at risk of readmission. Appropriate, timely and person-centred communication across all health care providers involved in transitions (in and out of hospital) as well as with patients and their families is critical to ensure a smooth and effective transition process. Digital health technologies can play an important role in improving person-centred communication across clinical settings and clinicians. This project will develop and test a Digital Bridge by connecting communication technologies already in use in hospital and primary care/community settings to improve communication between providers in hospital and in primary care, patients and family caregivers from admission to 6 months post-discharge. The investigators will engage with all the technology users to co-design the Digital Bridge, ensuring that how the investigators connect the existing technologies and adopt them into practice will meet the needs of providers, patients and their caregivers. Next hospital partners will adopt the technology into general medicine and rehabilitation services in hospital systems in Toronto (Sinai Health System) and Mississauga (Trillium Health Partners). The investigators will evaluate the Digital Bridge through a pre-post pragmatic trial, assessing impact on patient experience (quality of transition), patient outcomes (quality of life), transition processes (provider communication and teamwork), and system costs (economic evaluation). This project adopts an implementation science lens, allowing the investigators to collect qualitative data on enablers and barriers to adopting the Digital Bridge to help inform development of a scale and spread strategy.
Status | Recruiting |
Enrollment | 640 |
Est. completion date | March 30, 2025 |
Est. primary completion date | March 30, 2025 |
Accepts healthy volunteers | Accepts Healthy Volunteers |
Gender | All |
Age group | 60 Years and older |
Eligibility | Inclusion Criteria: - Patients with anticipated discharge home will be recruited at the time of admission to one of the services (i.e medicine or rehab) in the study. Patients aged 60 and over, with CCN defined as presenting with 3 or more chronic conditions from the 16 most prominent in the population, which is an established method to identifying patients with CCN. As the technology is only currently available in English, patients (or a caregiver) must be able to speak and read English. Patients with mild cognitive impairment will not be excluded if able to provide informed consent, and engage with the intervention (independently or with caregiver aid). Exclusion Criteria: - Previously participated in the study (in case of re-admission); discharge destination is another acute care facility, palliative care unit, complex continuing care, or long term care; died in hospital, cannot be contacted by telephone after discharge; unable to respond to survey question for any reason and lack of availability of family members and/or other caregivers willing and able to provide assistance. |
Country | Name | City | State |
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Canada | Sinai Health | Toronto | Ontario |
Lead Sponsor | Collaborator |
---|---|
Mount Sinai Hospital, Canada | Canadian Institutes of Health Research (CIHR), MOUNT SINAI HOSPITAL, Trillium Health Partners |
Canada,
Type | Measure | Description | Time frame | Safety issue |
---|---|---|---|---|
Primary | Care Transitions Measure (CTM3) | The CTM3 is a patient-reported measure of transition quality focusing on person-centredness and communication; appropriate as the focus of the Digital Bridge is to improve person-centred communication during transitions. The CTM-3 survey has been validated in similar patient populations transitioning from hospital to home and primary care, and in a systematic review of transitions measures was deemed to be the most acceptable measure of quality transitions. | At 1-2 weeks post-discharge | |
Secondary | Assessment for Quality of Life Scale 4D -AQoL-4D | a brief survey validated in similar populations, with demonstrated responsiveness and predictive validity with regard to entrance to long-term care | At baseline, 1-2 weeks, 3 and 6 months post-discharge | |
Secondary | Patient information sheet | This questionnaire will capture patient demographic and characteristic information such as age, gender, ethnicity, chronic illness profile, socio-economic status, and IT skills using the Patient Demographic forms. | Baseline | |
Secondary | Provider information sheet | This questionnaire will capture provider demographic and characteristic information such as age, gender, ethnicity, chronic illness profile, socio-economic status, and IT skills using the Provider Demographic forms. | Baseline | |
Secondary | Post-Study System Usability Questionnaire: PSSUQ | This questionnaire is designed to give an opportunity to talk about the reactions to the system that was used. These responses will help understand what aspects of the system that everyone is particularly concerned about, and the aspects everyone was satisfied with. | At 1-2weeks, 3 and 6 months post-discharge | |
Secondary | Patient/Caregiver self-reported costs | This questionnaire will ask about time and expenses relating to managing health conditions. | At 3 and 6 months post-discharge | |
Secondary | Caregiver information sheet | This questionnaire will allow us to understand who the caregivers are that participated in the study, and this will allow us to make sense of the data that will be collected during the working groups in a meaningful way. | Baseline |