Making Health Care Safer for Older Adults Receiving Skilled Home Health Care Services After Hospital Discharge

NCT05182060 | Completed

• 3 other identifiers: IRB002369411R01HS026599-013R01HS026599-02S1
• Study Type: interventional
• Target: 761
• Locations: 1 country
• Sites: 1

Brief Summary

Care transitions are the movement of a person from one healthcare setting to another. Older adults who require skilled home health care ("home health") services (e.g., home-based nursing) after hospital discharge are at high risk of experiencing early re-hospitalization. Home health agencies need strategies to ensure safe transitions, yet there is relatively little research to guide improvement efforts. The goal of the study is to develop and test tools to allow home health agencies to identify and act upon threats to older adults' safety in real time. The investigators first analyzed threats to older adult safety during hospital-to-home health transitions and refined a bundle of interventions through stakeholder engagement. This prospective pilot will implement and measure the bundle of interventions.

Conditions

Transitional Care; Frail Elderly; Home Health Care

Keywords

Transitional Care; Home Health Care; Frail Elderly; Stakeholder Participation; Quality Improvement; Medication Management

Outcome Measures

Primary Outcomes (1)

• ED visit use or re-hospitalization

  Whether or not the older adult experiences an ED visit use or re-hospitalization within 30 days of hospital discharge. This is a composite endpoint.

  Within 30 days after hospital discharge

Secondary Outcomes (2)

• Mortality within 30 days of hospital discharge

  Within 30 days after hospital discharge

• Existence of Unresolved Medication Issues

  Within 30 days after hospital discharge

Study Arms (2)

Transition Intervention

EXPERIMENTAL

We will implement a bundle of care transition safety resources with the assistance of home health coordinators at the study site. These resources include a link to a video about home health services, a caregiver assessment, a care task role assignment sheet, and a shopping list.

Behavioral: Transition Intervention

Control

NO INTERVENTION

We will select other home health provider teams that provide care to similar populations to serve as concurrent controls. No interventions will be administered.

Interventions

Transition Intervention BEHAVIORAL

We will implement a bundle of care transition safety strategies with the assistance of home care coordinators at the study site and corresponding home health provider teams (nurses, rehabilitation therapists). Home care coordinators will approach patients at the study site being referred for home health and provide resources to assist them with preparing for their transition home. These resources include a link to a video about home health services, a caregiver assessment, a care task role assignment sheet, and a shopping list. The study team will contact the older adult and caregiver by telephone within 48 hours of the home visit to confirm eligibility, explain the study, obtain consent for participation, and ask them to complete the the Hospital-to-Home Health Transition Quality Index (H3TQ) over the phone. Home health providers in the home will also complete the H3TQ.

Transition Intervention

Eligibility Criteria

• Age: 65 Years+
• Sex: all
• Healthy Volunteers: Yes
• Age Groups: Older Adult (65+)

You may qualify if:

• Older Adults
• Aged ≥ 65 years
• Can speak English or Spanish
• Is capable of assent
• Hospitalized on a medical or surgical service
• Referred for skilled home healthcare services (home health) after hospital discharge or skilled nursing facility (SNF) discharge
• Family Caregivers
• Unpaid
• Assist the older adult with at least one healthcare task. Healthcare tasks include the following activities: managing health care bills, scheduling medical appointments, getting to and from medical appointments, getting medical equipment, getting services, getting information, following a diet, obtaining medication, planning a medication schedule, taking medication, and deciding to stop or change medication.
• Home Health Providers
• Employed by participating sites
• Directly provide care to, or arrange services for, an eligible older adult

You may not qualify if:

• Community referrals to home health: Older adults referred to home health from the ambulatory setting (e.g., outpatient clinic) and without a recent hospitalization or SNF stay.

Sponsors & Collaborators

• Johns Hopkins University: lead
• Agency for Healthcare Research and Quality (AHRQ): collaborator

Study Sites (1)

Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine

Baltimore, Maryland, 21224, United States

Location

Study Officials

• Alicia Arbaje, MD, MPH, PhD

  Johns Hopkins University

  PRINCIPAL INVESTIGATOR

Study Design

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

Study Record Dates

• First Submitted: December 20, 2021
• First Posted: January 10, 2022
• Study Start: April 7, 2022
• Primary Completion: June 20, 2023
• Study Completion: July 31, 2023
• Last Updated: August 23, 2023

Record last verified: 2023-08

Locations

US (1)