Cargando…
Building a Digital Bridge to Support Patient-Centered Care Transitions From Hospital to Home for Older Adults With Complex Care Needs: Protocol for a Co-Design, Implementation, and Evaluation Study
BACKGROUND: Older adults with multimorbidity 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 inco...
Autores principales: | , , , , , , , , , , , , , , |
---|---|
Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
JMIR Publications
2020
|
Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7725647/ https://www.ncbi.nlm.nih.gov/pubmed/33237037 http://dx.doi.org/10.2196/20220 |
_version_ | 1783620742909263872 |
---|---|
author | Steele Gray, Carolyn Tang, Terence Armas, Alana Backo-Shannon, Mira Harvey, Sarah Kuluski, Kerry Loganathan, Mayura Nie, Jason X Petrie, John Ramsay, Tim Reid, Robert Thavorn, Kednapa Upshur, Ross Wodchis, Walter P Nelson, Michelle |
author_facet | Steele Gray, Carolyn Tang, Terence Armas, Alana Backo-Shannon, Mira Harvey, Sarah Kuluski, Kerry Loganathan, Mayura Nie, Jason X Petrie, John Ramsay, Tim Reid, Robert Thavorn, Kednapa Upshur, Ross Wodchis, Walter P Nelson, Michelle |
author_sort | Steele Gray, Carolyn |
collection | PubMed |
description | BACKGROUND: Older adults with multimorbidity 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 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-centered 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-centered health care transitions for older adults with CCN. The Digital Bridge builds on the foundation of two validated technologies: Care Connector, designed to improve interprofessional 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 two hospital systems in Ontario in acute and rehab settings (600 patients: 300 baseline and 300 implementation). The primary outcome measure for this study is the Care Transitions Measure–3 to assess transition quality. An embedded ethnography will be included to capture context and process data to inform the implementation assessment and 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 knowledge translation strategy and associated outputs. RESULTS: This project is underway and expected to be complete by Spring 2024. CONCLUSIONS: Given the real-world implementation of Digital Bridge, practice changes in the research sites and variable adherence to the implementation protocols are likely. Capturing and understanding these considerations through a mixed-methods approach will help identify the range of factors that may influence study results. Should a favorable evaluation suggest wide adoption of the proposed intervention, this project could lead to positive impact at patient, clinician, organizational, and health system levels. TRIAL REGISTRATION: ClinicalTrials.gov NCT04287192; https://clinicaltrials.gov/ct2/show/NCT04287192 INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/20220 |
format | Online Article Text |
id | pubmed-7725647 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2020 |
publisher | JMIR Publications |
record_format | MEDLINE/PubMed |
spelling | pubmed-77256472020-12-30 Building a Digital Bridge to Support Patient-Centered Care Transitions From Hospital to Home for Older Adults With Complex Care Needs: Protocol for a Co-Design, Implementation, and Evaluation Study Steele Gray, Carolyn Tang, Terence Armas, Alana Backo-Shannon, Mira Harvey, Sarah Kuluski, Kerry Loganathan, Mayura Nie, Jason X Petrie, John Ramsay, Tim Reid, Robert Thavorn, Kednapa Upshur, Ross Wodchis, Walter P Nelson, Michelle JMIR Res Protoc Protocol BACKGROUND: Older adults with multimorbidity 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 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-centered 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-centered health care transitions for older adults with CCN. The Digital Bridge builds on the foundation of two validated technologies: Care Connector, designed to improve interprofessional 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 two hospital systems in Ontario in acute and rehab settings (600 patients: 300 baseline and 300 implementation). The primary outcome measure for this study is the Care Transitions Measure–3 to assess transition quality. An embedded ethnography will be included to capture context and process data to inform the implementation assessment and 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 knowledge translation strategy and associated outputs. RESULTS: This project is underway and expected to be complete by Spring 2024. CONCLUSIONS: Given the real-world implementation of Digital Bridge, practice changes in the research sites and variable adherence to the implementation protocols are likely. Capturing and understanding these considerations through a mixed-methods approach will help identify the range of factors that may influence study results. Should a favorable evaluation suggest wide adoption of the proposed intervention, this project could lead to positive impact at patient, clinician, organizational, and health system levels. TRIAL REGISTRATION: ClinicalTrials.gov NCT04287192; https://clinicaltrials.gov/ct2/show/NCT04287192 INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/20220 JMIR Publications 2020-11-25 /pmc/articles/PMC7725647/ /pubmed/33237037 http://dx.doi.org/10.2196/20220 Text en ©Carolyn Steele Gray, Terence Tang, Alana Armas, Mira Backo-Shannon, Sarah Harvey, Kerry Kuluski, Mayura Loganathan, Jason X Nie, John Petrie, Tim Ramsay, Robert Reid, Kednapa Thavorn, Ross Upshur, Walter P Wodchis, Michelle Nelson. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 25.11.2020. https://creativecommons.org/licenses/by/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on http://www.researchprotocols.org, as well as this copyright and license information must be included. |
spellingShingle | Protocol Steele Gray, Carolyn Tang, Terence Armas, Alana Backo-Shannon, Mira Harvey, Sarah Kuluski, Kerry Loganathan, Mayura Nie, Jason X Petrie, John Ramsay, Tim Reid, Robert Thavorn, Kednapa Upshur, Ross Wodchis, Walter P Nelson, Michelle Building a Digital Bridge to Support Patient-Centered Care Transitions From Hospital to Home for Older Adults With Complex Care Needs: Protocol for a Co-Design, Implementation, and Evaluation Study |
title | Building a Digital Bridge to Support Patient-Centered Care Transitions From Hospital to Home for Older Adults With Complex Care Needs: Protocol for a Co-Design, Implementation, and Evaluation Study |
title_full | Building a Digital Bridge to Support Patient-Centered Care Transitions From Hospital to Home for Older Adults With Complex Care Needs: Protocol for a Co-Design, Implementation, and Evaluation Study |
title_fullStr | Building a Digital Bridge to Support Patient-Centered Care Transitions From Hospital to Home for Older Adults With Complex Care Needs: Protocol for a Co-Design, Implementation, and Evaluation Study |
title_full_unstemmed | Building a Digital Bridge to Support Patient-Centered Care Transitions From Hospital to Home for Older Adults With Complex Care Needs: Protocol for a Co-Design, Implementation, and Evaluation Study |
title_short | Building a Digital Bridge to Support Patient-Centered Care Transitions From Hospital to Home for Older Adults With Complex Care Needs: Protocol for a Co-Design, Implementation, and Evaluation Study |
title_sort | building a digital bridge to support patient-centered care transitions from hospital to home for older adults with complex care needs: protocol for a co-design, implementation, and evaluation study |
topic | Protocol |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7725647/ https://www.ncbi.nlm.nih.gov/pubmed/33237037 http://dx.doi.org/10.2196/20220 |
work_keys_str_mv | AT steelegraycarolyn buildingadigitalbridgetosupportpatientcenteredcaretransitionsfromhospitaltohomeforolderadultswithcomplexcareneedsprotocolforacodesignimplementationandevaluationstudy AT tangterence buildingadigitalbridgetosupportpatientcenteredcaretransitionsfromhospitaltohomeforolderadultswithcomplexcareneedsprotocolforacodesignimplementationandevaluationstudy AT armasalana buildingadigitalbridgetosupportpatientcenteredcaretransitionsfromhospitaltohomeforolderadultswithcomplexcareneedsprotocolforacodesignimplementationandevaluationstudy AT backoshannonmira buildingadigitalbridgetosupportpatientcenteredcaretransitionsfromhospitaltohomeforolderadultswithcomplexcareneedsprotocolforacodesignimplementationandevaluationstudy AT harveysarah buildingadigitalbridgetosupportpatientcenteredcaretransitionsfromhospitaltohomeforolderadultswithcomplexcareneedsprotocolforacodesignimplementationandevaluationstudy AT kuluskikerry buildingadigitalbridgetosupportpatientcenteredcaretransitionsfromhospitaltohomeforolderadultswithcomplexcareneedsprotocolforacodesignimplementationandevaluationstudy AT loganathanmayura buildingadigitalbridgetosupportpatientcenteredcaretransitionsfromhospitaltohomeforolderadultswithcomplexcareneedsprotocolforacodesignimplementationandevaluationstudy AT niejasonx buildingadigitalbridgetosupportpatientcenteredcaretransitionsfromhospitaltohomeforolderadultswithcomplexcareneedsprotocolforacodesignimplementationandevaluationstudy AT petriejohn buildingadigitalbridgetosupportpatientcenteredcaretransitionsfromhospitaltohomeforolderadultswithcomplexcareneedsprotocolforacodesignimplementationandevaluationstudy AT ramsaytim buildingadigitalbridgetosupportpatientcenteredcaretransitionsfromhospitaltohomeforolderadultswithcomplexcareneedsprotocolforacodesignimplementationandevaluationstudy AT reidrobert buildingadigitalbridgetosupportpatientcenteredcaretransitionsfromhospitaltohomeforolderadultswithcomplexcareneedsprotocolforacodesignimplementationandevaluationstudy AT thavornkednapa buildingadigitalbridgetosupportpatientcenteredcaretransitionsfromhospitaltohomeforolderadultswithcomplexcareneedsprotocolforacodesignimplementationandevaluationstudy AT upshurross buildingadigitalbridgetosupportpatientcenteredcaretransitionsfromhospitaltohomeforolderadultswithcomplexcareneedsprotocolforacodesignimplementationandevaluationstudy AT wodchiswalterp buildingadigitalbridgetosupportpatientcenteredcaretransitionsfromhospitaltohomeforolderadultswithcomplexcareneedsprotocolforacodesignimplementationandevaluationstudy AT nelsonmichelle buildingadigitalbridgetosupportpatientcenteredcaretransitionsfromhospitaltohomeforolderadultswithcomplexcareneedsprotocolforacodesignimplementationandevaluationstudy |