Digital Bridge: Using Technology to Support Patient-centered Care Transitions From Hospital to Home

NCT04287192 | Recruiting

• 1 other identifier: Digital Bridge
• Study Type: interventional
• Target: 640
• Locations: 1 country
• Sites: 1

Brief Summary

Older adults who live with multiple chronic conditions are more likely to experience frequent admissions and discharges from hospital. These transitions are often challenging and leave people at risk of readmission. Appropriate, timely and person-centred communication across all health care providers involved in transitions (in and out of hospital) as well as with patients and their families is critical to ensure a smooth and effective transition process. Digital health technologies can play an important role in improving person-centred communication across clinical settings and clinicians. This project will develop and test a Digital Bridge by connecting communication technologies already in use in hospital and primary care/community settings to improve communication between providers in hospital and in primary care, patients and family caregivers from admission to 6 months post-discharge. The investigators will engage with all the technology users to co-design the Digital Bridge, ensuring that how the investigators connect the existing technologies and adopt them into practice will meet the needs of providers, patients and their caregivers. Next hospital partners will adopt the technology into general medicine and rehabilitation services in hospital systems in Toronto (Sinai Health System) and Mississauga (Trillium Health Partners). The investigators will evaluate the Digital Bridge through a pre-post pragmatic trial, assessing impact on patient experience (quality of transition), patient outcomes (quality of life), transition processes (provider communication and teamwork), and system costs (economic evaluation). This project adopts an implementation science lens, allowing the investigators to collect qualitative data on enablers and barriers to adopting the Digital Bridge to help inform development of a scale and spread strategy.

Conditions

Older Adults With Complex Care Needs

Outcome Measures

Primary Outcomes (1)

• Care Transitions Measure (CTM3)

  The CTM3 is a patient-reported measure of transition quality focusing on person-centredness and communication; appropriate as the focus of the Digital Bridge is to improve person-centred communication during transitions. The CTM-3 survey has been validated in similar patient populations transitioning from hospital to home and primary care, and in a systematic review of transitions measures was deemed to be the most acceptable measure of quality transitions.

  At 1-2 weeks post-discharge

Secondary Outcomes (6)

• Assessment for Quality of Life Scale 4D -AQoL-4D

  At baseline, 1-2 weeks, 3 and 6 months post-discharge

• Patient information sheet

  Baseline

• Provider information sheet

  Baseline

• Post-Study System Usability Questionnaire: PSSUQ

  At 1-2weeks, 3 and 6 months post-discharge

• Patient/Caregiver self-reported costs

  At 3 and 6 months post-discharge

Study Arms (2)

Control

NO INTERVENTION

Control: Control participants will complete surveys at 4 time points (baseline, 1-2 weeks, 3 month and 6 months after discharge). The surveys will capture data on demographics, assess their transition quality, self-reported costs, and assess their quality of life. Aside from completion of these surveys, no changes to their usual care will occur.

(Digital Bridge intervention)

EXPERIMENTAL

Experimental (Digital Bridge intervention) participants will complete surveys at 4 time points (baseline, 1-2 weeks, 3 month and 6 months after discharge). The surveys will capture data on demographics, assess their transition quality, self-reported costs, assess their quality of life, and goal attainment. One to two days before discharge, patients will work with their team to develop the PODS in Care Connector. Once the PODS is created, the patient and hospital provider will be prompted to set transition goals using the ePRO tool.

Other: Digital Bridge:Tool Intervention

Interventions

Digital Bridge:Tool Intervention OTHER

Our Digital Bridge is an integration of the Care Connector and ePRO technologies that will support care transitions by: 1) inviting PCPs to access Care Connector while the patient is in hospital, allowing for asynchronous communication via the messaging feature for proactive discharge planning, 2) facilitating the inclusion of inter-professional recommendations in the discharge module (e.g. diet and mobility) typically missing from traditional physician generated discharge summaries, 3) electronic generation of PODS for use in patient-centred discharge teaching, 4) providing patients electronic access to PODS post discharge to facilitate use of information at home, 5) adoption of digital enabled goal-oriented process to engage patients and families in discharge process, and 6) providing ongoing self-management support for patients using ePRO for the vulnerable period 6 months post discharge.

(Digital Bridge intervention)

Eligibility Criteria

• Age: 60 Years+
• Sex: all
• Healthy Volunteers: Yes
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• Patients with anticipated discharge home will be recruited at the time of admission to one of the services (i.e medicine or rehab) in the study. Patients aged 60 and over, with CCN defined as presenting with 3 or more chronic conditions from the 16 most prominent in the population, which is an established method to identifying patients with CCN. As the technology is only currently available in English, patients (or a caregiver) must be able to speak and read English. Patients with mild cognitive impairment will not be excluded if able to provide informed consent, and engage with the intervention (independently or with caregiver aid).

You may not qualify if:

• Previously participated in the study (in case of re-admission); discharge destination is another acute care facility, palliative care unit, complex continuing care, or long term care; died in hospital, cannot be contacted by telephone after discharge; unable to respond to survey question for any reason and lack of availability of family members and/or other caregivers willing and able to provide assistance.

Sponsors & Collaborators

• Mount Sinai Hospital, Canada: lead
• MOUNT SINAI HOSPITAL: collaborator
• Trillium Health Partners: collaborator

Study Sites (1)

Sinai Health

Toronto, Ontario, M5G 1X5, Canada

RECRUITING

Related Publications (2)

• Singh H, Armas A, Law S, Tang T, Steele Gray C, Cunningham HV, Thombs R, Ellen M, Sritharan J, Nie JX, Plett D, Jarach CM, Thavorn K, Nelson MLA. How digital health solutions align with the roles and functions that support hospital to home transitions for older adults: a rapid review study protocol. BMJ Open. 2021 Feb 25;11(2):e045596. doi: 10.1136/bmjopen-2020-045596.

  PMID: 33632755 DERIVED

• Steele Gray C, Tang T, Armas A, Backo-Shannon M, Harvey S, Kuluski K, Loganathan M, Nie JX, Petrie J, Ramsay T, Reid R, Thavorn K, Upshur R, Wodchis WP, Nelson M. 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. JMIR Res Protoc. 2020 Nov 25;9(11):e20220. doi: 10.2196/20220.

  PMID: 33237037 DERIVED

Study Officials

• Carolyn Steele Gray, PhD

  Sinai Health System

  PRINCIPAL INVESTIGATOR

• Terence Tang, MD

  Trillium Health

  PRINCIPAL INVESTIGATOR

• Michelle Nelson, PhD

  Sinai Health System

  PRINCIPAL INVESTIGATOR

Central Study Contacts

Carolyn Steele Gray, PhD

CONTACT

(416) 461-8252; Carolyn.SteeleGray@sinaihealth.ca

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: NON RANDOMIZED
• Masking: NONE
• Purpose: SUPPORTIVE CARE
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Model Details: The investigators will conduct a non-randomized control trial to understand the impact of the intervention. For each site (Sinai Health System and THP - both Mississauga and Credit Valley sites) and each service, half of the participating wards will be designated as control while the other half will be designated as intervention. The investigators will collect baseline data from all wards (control and intervention) during phase 1 while co-design is on-going and the intervention has not been deployed. During phase 2, after co-design is complete, the co-designed technology intervention and workflow will be rolled out to only the intervention wards. The investigators will then collect data (identical to what was collected at baseline) from all wards (control and intervention) to understand the impact of technology by examining the differential change between control and intervention wards (difference in difference approach).

Study Record Dates

• First Submitted: February 25, 2020
• First Posted: February 27, 2020
• Study Start: April 15, 2023
• Primary Completion: March 30, 2026
• Study Completion: March 30, 2026
• Last Updated: October 3, 2025

Record last verified: 2024-11

Data Sharing

• IPD Sharing: Will share
• Shared Documents: STUDY PROTOCOL, CSR
• Time Frame: Data will be available through 2022-2024.
• Access Criteria: Open access peer reviewed journal publication

Locations

CA (1)