Care transitions are the movement of a person from one healthcare setting to another. Older adults who require skilled home health care (SHHC) services (e.g., home-based nursing) after hospital discharge are at high risk of experiencing early re-hospitalization. SHHC agencies need strategies to ensure safe transitions, yet there is relatively little research to guide improvement efforts. The goal of the current proposal is to develop tools to allow SHHC agencies to identify and act upon threats to older adults' safety in real time.
Specific Aim 1 : Analyze threats to older adult safety during hospital-to-SHHC transitions through a prospective cohort study. 1a: Describe the incidence of threats to older adults' safety (as measured by the Index of SHHC Transition Quality applied to the transitions of recently hospitalized older adults) and identify strategies for improvement from the perspectives of SHHC providers, older adults, and informal caregivers. 1b: Compare threats identified by SHHC providers versus older adults'/caregivers' Index responses. 1c: Identify which Index threats are drivers of suboptimal outcomes: (1) 30-day emergency department (ED) use or re- hospitalization; (2) older adult/caregiver/SHHC provider transition experience; (3) timely resolution of medication issues; and (4) mortality.
Specific Aim 2 : Refine a bundle of interventions through stakeholder engagement. Guided by a participatory ergonomics approach, we will form intervention refinement teams (IRTs) including older adults/caregivers, SHHC providers, and SHHC leadership at two large SHHC agencies. In preparation for pilot testing of the bundle of interventions, IRTs will meet to (1) present key drivers of suboptimal outcomes (from SA1) to prioritize areas for SHHC performance improvement, (2) identify system constraints and design requirements for the bundle, (3) present and select strategies for inclusion in the bundle, (4) evaluate workflow and assign roles for implementation of the bundle, and (5) anticipate barriers and brainstorm solutions.
Specific Aim 3 : Pilot test bundle implementation in a second prospective cohort study to test feasibility. We will use the Index to identify older adults experiencing high-risk hospital-to-SHHC transitions and deliver the bundle to these older adults. We will investigate 30-day ED use, re-hospitalization, and mortality for the intervention group and compare to concurrent and historical controls. IRTs will meet to assess the impact of the bundle as assessed through surveys and focus groups of older adults/caregivers and SHHC providers discussing (1) acceptability, (2) appropriateness, (3) identification of barriers to implementation, and (4) analysis of impact on workflow, including unanticipated consequences. Completion of these aims will result in tools to improve the quality of older adults' hospital-to-SHHC transitions. Study findings will build the foundation for future work, including a randomized-controlled-trial testing the bundle in a broader population of older adults receiving SHHC services after hospital discharge.

Public Health Relevance

The aging of the population is leading to greater reliance on care delivered in the home, the most common and poorly understood healthcare delivery setting. Older adults who require nursing services after hospital discharge are at high risk of returning to the hospital within a short time frame. The overall goal of the proposed study is to provide real-time feedback to home healthcare nurses to identify and reduce potential safety risks when older adults return home from the hospital.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Research Project (R01)
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Healthcare Patient Safety and Quality Improvement Research (HSQR)
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Haugstetter, Monika
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Johns Hopkins University
Schools of Medicine
United States
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