Comprehensive Discharge Planning for Frail Elderly
(HOME Trial)
Trial Summary
What is the purpose of this trial?
A large number of frail older adults have difficulty performing activities of daily living and resuming former roles in the months following hospital discharge. This increases the risk of unplanned hospital readmissions and emergency visits after they return home. Comprehensive, patient-centered discharge planning has been reported to improve older adults' ability to perform activities of daily living and to reduce readmission rates after hospital discharge. However, to our knowledge, no evidence-based discharge protocol is routinely used in Canada with the frail population. An innovative discharge planning intervention called "HOME" was recently developed in Australia, which includes: 1) hospital based partnership with patient and family to establish goal setting and problem solving; 2) pre-discharge home assessment to address safety issues and problems with patient and family; 3) post-discharge home assessment and in-home training to address unmet needs; and 4) follow-up telephone calls to provide ongoing support to patient and family. A Canadian version of HOME has been developed. This will be followed by a large trial to investigate if this intervention increases functioning in daily life activities and decreases hospital and emergency readmissions for frail patients who are discharged home. Our proposed study is a preliminary and necessary step to identify problems that may arise during this large trial and address them proactively. If proven beneficial, the Canadian version of HOME would be an appropriate, applicable and acceptable intervention to improve patients' experiences and outcomes as well as change health practice surroundings discharge planning with frail older adults.
Will I have to stop taking my current medications?
The trial information does not specify whether you need to stop taking your current medications.
What data supports the effectiveness of the treatment HOME, HOME Discharge Planning Intervention, Comprehensive Patient-centered Hospital Discharge Planning Intervention for frail elderly patients?
Research shows that patient-centered discharge planning can improve health outcomes for vulnerable adults, and including family caregivers in the process may enhance patient outcomes and quality of care. Effective discharge planning is linked to better patient health and satisfaction, especially when posthospital services are organized and follow-up programs are in place.12345
Is comprehensive discharge planning for frail elderly generally safe?
What makes the HOME Discharge Planning Intervention unique compared to other treatments for frail elderly patients?
Research Team
Véronique Provencher
Principal Investigator
Université de Sherbrooke
Eligibility Criteria
This trial is for frail elderly individuals aged 70 or older who have mild cognitive impairment and are expected to stay in the hospital for at least 5 days. They must be planning to return home after discharge, speak French or English, and have a family member willing to participate.Inclusion Criteria
Timeline
Screening
Participants are screened for eligibility to participate in the trial
In-hospital Intervention
The clinician will focus on building a rapport with the patient and family members. Information will be gathered about the participant's home environment and functional ability.
Pre-discharge Home Assessment
Clinician will conduct a pre-discharge home assessment with patient and family to evaluate the environment, identify potential problems, and suggest appropriate ways to address them.
Post-discharge Home Assessment
Post-discharge home assessment will be conducted to provide additional in-home training and follow up on any of the patient's unmet needs.
Follow-up
Follow-up telephone calls will be made to provide ongoing support to participant and family and encourage self-problem solving and independence.
Follow-up Monitoring
Participants are monitored for safety and effectiveness after treatment, with assessments at 1 and 3 months post-discharge.
Treatment Details
Interventions
- HOME
HOME is already approved in Canada for the following indications:
- Improving daily life activities for frail older adults
- Reducing hospital and emergency readmissions
Find a Clinic Near You
Who Is Running the Clinical Trial?
Université de Sherbrooke
Lead Sponsor
Canadian Institutes of Health Research (CIHR)
Collaborator