Comprehensive Care Transition: A Trial of an Enhanced Care Transition Process in Dementia

NCT02415504 | Terminated

• 1 other identifier: REB14-45
• Study Type: interventional
• Target: 29
• Locations: 1 country
• Sites: 1

Brief Summary

This pilot study examines the impact of an enhanced care transition process vs. usual care for persons with dementia admitted to a transitional unit (hospital or LTC) for management of behavioural and psychological symptoms of dementia (BPSD) with a planned discharge to long term care (LTC) facilities or other hospital units. Deficiencies in discharge processes can contribute to poor outcomes (e.g., readmissions), and there is a dearth of research on how to improve care transitions for persons with BPSD. The investigators aim to improve the care transition process for persons with dementia and BPSD utilizing an enhanced care transition process that will contain up to 6 elements: integrated behavioural care plans, videos, patient specific briefcase containing activities to reduce BPSD, in-person care transition meeting, in-person care demonstration (when possible), and follow up visits with a transition team. The ability to determine the effect of enhanced care transitions on the clinical course of patients with planned discharge to LTC or hospital may allow for improved outcomes and an overall increased efficiency of post discharge care.

Conditions

Dementia; BPSD

Keywords

Care transition; Behavioural and psychological symptoms of dementia; BPSD; Dementia; Persons with dementia; Discharge processes

Outcome Measures

Primary Outcomes (1)

• Post-Care Transition (PCT) questionnaire

  Likert scales and open-ended questions measuring change in the transitioned resident's identified behaviour(s).

  Change in resident's baseline behaviour(s) at 2 and 4 weeks

Secondary Outcomes (8)

• Social work assessment questionnaire

  At 6 months after baseline

• Substitute Decision Maker (SDM) satisfaction questionnaire

  At baseline

• Substitute Decision Maker (SDM) satisfaction questionnaire

  Change from baseline at 2 weeks

• Substitute Decision Maker (SDM) questionnaire

  At baseline

• Substitute Decision Maker (SDM) questionnaire

  Change in resident's baseline behaviour(s) at 2 and 4 weeks

Study Arms (2)

Enhanced care transition

EXPERIMENTAL

The enhanced care transition will offer: (1) an integrated behavioural care plan, (2) an in- person discharge meeting including family, post-care transition staff (LTC or another hospital unit) and unit staff, (3) videos of responsive behaviours and non-pharmacological interventions, (4) a briefcase of favoured activities, (5) an in-person care demonstration, and (6) involvement of a transitional care team.

Behavioral: Enhanced care transition

Standard care transition

OTHER

The standard care transition varies by unit, and either consists of: (1) a discipline specific care plan, (2) a phone discharge meeting between unit staff and post-care transition staff (LTC or another hospital unit) and (3) a follow-up phone call with social work OR (1) a discipline specific care plan, (2) an in-person meeting between unit staff and (family) caregivers, (3) involvement of a transitional care team, and (4) a follow-up phone call with social work.

Behavioral: Standard care transition

Interventions

Enhanced care transition BEHAVIORAL

Enhanced care transition discharge package: (1) an integrated behavioural care plan, (2) an in-person discharge meeting including family, post-care transition staff (LTC or another hospital unit) and unit staff, (3) videos of responsive behaviours and non-pharmacological interventions, (4) a briefcase of favoured activities, (5) an in-person care demonstration, and (6) involvement of a transitional care team.

Enhanced care transition

Standard care transition BEHAVIORAL

Standard care transition discharge package: The standard care transition varies by unit, and either consists of: (1) a discipline specific care plan, (2) a phone discharge meeting between unit staff and post-care transition staff (LTC or another hospital unit) and (3) a follow-up phone call with social work OR (1) a discipline specific care plan, (2) an in-person meeting between unit staff and (family) caregivers, (3) involvement of a transitional care team, and (4) a follow-up phone call with social work.

Standard care transition

Eligibility Criteria

• Age: 55 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• Patients on behavioural transitional support unit's at Baycrest (Behavioural Neurology Unit, transitional Behavioural Support Unit) who are admitted for behavioural and psychological symptoms of dementia (BPSD)
• Diagnosed with a degenerative dementia
• Over 55 years old at the time of discharge, with a planned discharge to a long-term care (LTC) facility or another hospital unit will be eligible for the study

You may not qualify if:

• None

Sponsors & Collaborators

• Baycrest: lead
• Ontario Ministry of Health and Long Term Care: collaborator

Study Sites (1)

Baycrest

Toronto, Ontario, M6A 2E1, Canada

Location

Related Publications (2)

• Viggiano T, Pincus HA, Crystal S. Care transition interventions in mental health. Curr Opin Psychiatry. 2012 Nov;25(6):551-8. doi: 10.1097/YCO.0b013e328358df75.

  PMID: 22992544 BACKGROUND

• Coleman EA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc. 2003 Apr;51(4):549-55. doi: 10.1046/j.1532-5415.2003.51185.x.

  PMID: 12657078 BACKGROUND

MeSH Terms

Conditions

Dementia

Condition Hierarchy (Ancestors)

Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Neurocognitive Disorders; Mental Disorders

Study Officials

• Colleen Ray, PhD

  Neuropsychology and Cognitive Health at Baycrest

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: NONE
• Purpose: SUPPORTIVE CARE
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Ph.D., C.Psych

Study Record Dates

• First Submitted: December 5, 2014
• First Posted: April 14, 2015
• Study Start: July 1, 2014
• Primary Completion: May 1, 2016
• Study Completion: May 1, 2016
• Last Updated: September 22, 2016

Record last verified: 2016-09

Data Sharing

• IPD Sharing: Will not share

Locations

CA (1)