JMIR Publications

ABSTRACT

Background:

Older adults with multi-morbidity and complex care needs (CCN) are among those most likely to experience frequent care transitions between settings, particularly from hospital to home. Transition periods mark vulnerable moments in care for individuals with CCN. Poor communication and incomplete information transfer between the various clinicians and organizations involved in the transition from hospital to home can impede access to needed support and resources. Establishing digitally supported communication that enables person-centred care and supported self-management may offer significant advantages as we support older adults with CCN transitioning from hospital to home.

Objective:

This protocol outlines the plan for the development, implementation and evaluation of a Digital Bridge co-designed to support person-centred health care transitions for older adults with CCN. The Digital Bridge builds on the foundation of two validated technologies; Care Connector, designed to improve inter-professional communication in hospital, and the electronic Patient Reported Outcomes (ePRO) tool, designed to support goal-oriented care planning and self-management in primary care settings. This project poses three overarching research questions that focus on adapting the technology to local contexts, evaluating the impact of the Digital Bridge in relation to the quadruple aim, and exploring the potential to scale and spread the technology.

Methods:

The study includes two phases: workflow co-design (PHASE 1), followed by implementation and evaluation (PHASE 2). PHASE 1 will include iterative co-design working groups with patients, caregivers, hospital providers and primary care providers to develop a transition workflow that will leverage the use of Care Connector and ePRO to support communication through the transition process. PHASE 2 will include implementation and evaluation of the Digital Bridge within one acute hospital system and one rehab hospital system in Ontario (n=600 patients; 300 baseline, 300 implementation). The primary outcome measure for this study is the Care Transitions Measure-3 to assess transition quality. An embedded ethnography will also be included to capture context and process data to inform the implementation assessment and the development of a scale and spread strategy. An Integrated Knowledge Translation approach is taken to inform the study. An Advisory Group will be established to provide insight and feedback regarding the project design and implementation, leading the development of the project KT strategy and associated outputs.

Results:

This study is funded by the Canadian Institute for Health Research Team Grant in Transitions in Care (FRN- 165733), is approved by the Trillium Health Partners REB, and undergoing review by the Sinai Health REB.

Conclusions:

Given the ‘real world’ implementation of Digital Bridge, there will be several practice changes in the research sites and variable adherence to the implementation protocols. Capturing and understanding these considerations is essential in order to identity the range of factors that may influence study Adopting a pragmatic trial design with an embedded case study will provide insights into outcomes as well as the mechanisms that are likely driving those outcomes. Clinical Trial: ClinicalTrials.gov ID: NCT04287192