Comprehensive Discharge Planning for Frail Elderly

(HOME Trial)

Overseen By Véronique Provencher

Age: 65+

Sex: Any

Trial Phase: Academic

Sponsor: Université de Sherbrooke

Disqualifiers: Under 70, Severe cognitive impairment, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Approved in 2 Jurisdictions This treatment is already approved in other countries

Compensation: Varies

Number of Visits: 1

72 Participants Needed

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. ^{1 2 3 4 5}

Is comprehensive discharge planning for frail elderly generally safe?

The research suggests that comprehensive discharge planning is generally safe and aims to improve patient care after leaving the hospital, although there are gaps in the process that need improvement to prevent adverse events. ^{3 6 7 8 9}

What makes the HOME Discharge Planning Intervention unique compared to other treatments for frail elderly patients?

The HOME Discharge Planning Intervention is unique because it focuses on comprehensive, patient-centered discharge planning specifically tailored for frail elderly patients, involving personalized care plans and follow-up, which are not typically included in standard discharge processes. ^{3 4 5 8 10}

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

I can speak French or English.

should have a family member who agrees to participate in the study

I plan to live at home after being discharged from the hospital.

Timeline

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

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.

During hospital stay

In-hospital

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.

± 5 days prior to expected discharge

Home visit

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.

<1 week after discharge

Home visit

Follow-up

Follow-up telephone calls will be made to provide ongoing support to participant and family and encourage self-problem solving and independence.

2-4 weeks post-discharge

Telephone calls

Follow-up Monitoring

Participants are monitored for safety and effectiveness after treatment, with assessments at 1 and 3 months post-discharge.

3 months

Assessments at 1 and 3 months post-discharge

Treatment Details

Interventions

• HOME

Trial Overview The 'HOME' intervention is being tested, which includes collaborative goal setting with patients and families, pre- and post-discharge home assessments for safety and needs, plus follow-up support calls aimed at improving daily functioning and reducing readmissions.

Participant Groups

Group I: Experimental Experimental Treatment 1 Intervention

HOME will be delivered by a community-based OT, who will be involved in the hospital discharge planning, trained by the PI. The HOME intervention comprises 4 phases: Phase 1 (in hospital): 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. Phase 2 (± 5 days prior to expected discharge): 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. Phase 3 (\<1 week after discharge): Post-discharge home assessment will be conducted to provide additional in-home training and follow up on any of the patient's unmet needs. Phase 4 (2-4 weeks post-discharge): Follow-up telephone calls will be made to provide ongoing support to participant and family and encourage self-problem solving and independence.

Group II: Usual care Active Control 1 Intervention

Usual care group will receive the customary discharge planning assessment by a different clinician (OT). During this assessment, according to usual care, information regarding the participants' ability to perform activities of daily living and regarding their home environment is gathered and used to plan for discharge. Usual care group will not receive an OT home assessment as this is not part of usual care. If the clinician identifies a potential need for assistive equipment and home modification needs, patients will be referred to community-based homecare services as is the current practice, and a home visit may be performed following discharge, typically after an lengthy wait (weeks, months) for service.

HOME is already approved in Canada for the following indications:

Approved in Canada as HOME for:

• Improving daily life activities for frail older adults
• Reducing hospital and emergency readmissions

Who Is Running the Clinical Trial?

Université de Sherbrooke

Lead Sponsor

Trials

317

Recruited

79,300+

Canadian Institutes of Health Research (CIHR)

Collaborator

Trials

1,417

Recruited

26,550,000+

Findings from Research

Involving caregivers in discharge education for elderly patients with community-acquired pneumonia can significantly reduce unplanned hospital readmissions within 30 days, as shown by a systematic review of five studies.

While the evidence suggests that structured caregiver education interventions can lead to a small reduction in readmissions, the variability in caregiver learning needs and the lack of uniform effectiveness highlight the need for more targeted research in this area.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Effectiveness of patient-caregiver dyad discharge interventions on hospital readmissions of elderly patients with community acquired pneumonia: a systematic review. McLeod-Sordjan, R., Krajewski, B., Jean-Baptiste, P., et al.[2020]

The study surveyed 16 discharge planners from both rural and metropolitan hospitals to evaluate the effectiveness of discharge-planning processes in acute-care settings.

While most discharge planners focused on client-centered activities, they often failed to fully assess clients' resources and care deficits upon admission, which could impact the quality of discharge planning.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

What do discharge planners plan? Implications for older Medicare patients. Wacker, RR., Kundrat, MA., Keith, PM.[2017]

The HOME Initiative, involving 52 internal medicine residents, demonstrated that structured home visits to recently discharged patients significantly improved residents' patient-centered discharge planning skills and culturally sensitive care delivery.

Residents who participated in the intervention showed enhanced communication skills, allowing them to better understand patients' illness narratives and assess their safety, functional status, and health literacy, indicating the effectiveness of this educational approach.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Using Post-discharge Home Visitation to Improve Cultural Sensitivity and Patient-centered Discharge Planning by Internal Medicine Trainees. Wilson, JD., Shaw, KC., Feldman, LS.[2021]

The PRO-HOME program is a pilot randomized controlled study involving 60 hospitalized older patients (aged 65+) aimed at reducing hospital stay length through a multicomponent intervention that includes physical activity, cognitive training, and lifestyle education.

The study incorporates advanced architectural and technological components in a mini apartment setting, with the goal of improving physical and cognitive performance and overall quality of life for frail older patients upon discharge.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The PRO-HOME Project. A multicomponent intervention for the protected discharge from the hospital of multimorbid and polytreated older individuals by using innovative technologies: A pilot study. Pilotto, A., Volta, E., Barbagelata, M., et al.[2023]

Effective discharge planning programs are essential for addressing the posthospital needs of frail elderly patients, leading to improved health status and patient satisfaction.

Key components of successful discharge planning include thorough admission assessments and organized follow-up programs to ensure continuity of care after hospital discharge.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Characteristics of effective discharge planning programs for the frail elderly. Haddock, KS.[2019]

The Modified Physician-PREPARED scale was validated as a reliable tool to measure outpatient physicians' perceptions of hospital discharge quality, based on a survey of 403 patients and a 76% response rate.

Higher scores on the scale were associated with better discharge planning and communication, particularly when outpatient physicians were involved in the discharge process and aware of community support services.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Discharge planning scale: community physicians' perspective. Graumlich, JF., Grimmer-Somers, K., Aldag, JC.[2015]

In a study of 300 elderly patients, it was found that 48.7% experienced high-risk adverse health events within 12 months after discharge, highlighting the vulnerability of this population post-hospitalization.

The study developed a predictive model that outperformed existing screening tools (Pra and LACE index) in identifying high-risk patients, suggesting that improved discharge planning and continuity of care are essential for reducing readmissions and enhancing patient outcomes.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Exploration of risk factors for high-risk adverse events in elderly patients after discharge and comparison of discharge planning screening tools. Yen, HY., Lin, SC., Chi, MJ.[2022]

Comprehensive nursing discharge planning did not show benefits for elderly medical inpatients, with most patients only benefiting from a few components of the discharge process.

Patients who received more discharge planning components reported feeling less ready to go home and experienced higher rates of readmission within 30 days, indicating a need for improvement in the discharge planning process.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Nursing discharge planning for older medical inpatients in Switzerland: A cross-sectional study. Mabire, C., Büla, C., Morin, D., et al.[2017]

The Brief PREPARED (B-PREPARED) instrument, tested in a study of 460 patients, effectively measures how prepared patients feel for discharge from the hospital, showing good internal consistency and predictive validity.

Higher scores on the B-PREPARED scale correlate with better satisfaction regarding medication information and predict fewer emergency department visits after discharge, indicating its potential usefulness in improving discharge processes.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Brief scale measuring patient preparedness for hospital discharge to home: Psychometric properties. Graumlich, JF., Novotny, NL., Aldag, JC.[2015]

A comprehensive discharge planning protocol for elderly patients, implemented by nurse specialists, significantly reduced readmission rates and healthcare costs within the first 6 weeks after hospital discharge, based on a randomized clinical trial involving 276 patients and 125 caregivers.

The intervention was particularly effective for patients in medical groups, leading to fewer total days rehospitalized and lower charges for post-discharge healthcare services, highlighting the importance of tailored discharge planning for improving outcomes in older adults.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Naylor, M., Brooten, D., Jones, R., et al.[2022]

References

1. Australia pubmed.ncbi.nlm.nih.gov

Effectiveness of patient-caregiver dyad discharge interventions on hospital readmissions of elderly patients with community acquired pneumonia: a systematic review. [2020]

2. United States pubmed.ncbi.nlm.nih.gov

What do discharge planners plan? Implications for older Medicare patients. [2017]

3. United States pubmed.ncbi.nlm.nih.gov

Using Post-discharge Home Visitation to Improve Cultural Sensitivity and Patient-centered Discharge Planning by Internal Medicine Trainees. [2021]

4. England pubmed.ncbi.nlm.nih.gov

The PRO-HOME Project. A multicomponent intervention for the protected discharge from the hospital of multimorbid and polytreated older individuals by using innovative technologies: A pilot study. [2023]

5. United States pubmed.ncbi.nlm.nih.gov

Characteristics of effective discharge planning programs for the frail elderly. [2019]

6. United States pubmed.ncbi.nlm.nih.gov

Discharge planning scale: community physicians' perspective. [2015]

7. United States pubmed.ncbi.nlm.nih.gov

Exploration of risk factors for high-risk adverse events in elderly patients after discharge and comparison of discharge planning screening tools. [2022]

8. United States pubmed.ncbi.nlm.nih.gov

Nursing discharge planning for older medical inpatients in Switzerland: A cross-sectional study. [2017]

9. United States pubmed.ncbi.nlm.nih.gov

Brief scale measuring patient preparedness for hospital discharge to home: Psychometric properties. [2015]

10. United States pubmed.ncbi.nlm.nih.gov

Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. [2022]