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Digital Communication Tool for Post-Hospitalization Care in Older Adults (DB Trial)

N/A

Recruiting

Led By Carolyn Steele Gray, PhD

Research Sponsored by Mount Sinai Hospital, Canada

Eligibility Criteria Checklist

Specific guidelines that determine who can or cannot participate in a clinical trial

Must have

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.

Be older than 18 years old

Must not have

Died in hospital.

Discharge destination is another acute care facility, palliative care unit, complex continuing care, or long term care.

Timeline

Screening 3 weeks

Treatment Varies

Follow Up at 1-2weeks, 3 and 6 months post-discharge

Awards & highlights

No Placebo-Only Group

Summary

This trial will develop and test a "Digital Bridge" to improve communication between hospital and primary care providers, patients, and their caregivers. The goal is to reduce risk of readmission and improve patient experience and outcomes.

Who is the study for?

This trial is for older adults aged 60 and over with complex care needs, defined as having three or more chronic conditions. Participants must speak and read English, be able to respond to surveys, have family or caregivers available if needed, and plan to go home after hospital discharge.

What is being tested?

The Digital Bridge tool intervention is being tested. It aims to improve communication between healthcare providers in hospitals and primary care settings, patients, and their families from admission until six months after leaving the hospital.

What are the potential side effects?

Since this trial involves a digital communication tool rather than medication or medical procedures, traditional side effects are not applicable. However, participants may experience issues related to technology use such as privacy concerns or stress due to technical difficulties.

Eligibility Criteria

Inclusion Criteria

You may be eligible if you check “Yes” for the criteria below

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I am 60 or older with 3 or more long-term health conditions.

Exclusion Criteria

You may be eligible for the trial if you check “No” for criteria below:

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Not applicable as the patient has passed away.

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I will be moved to another care facility or a long-term care after discharge.

Timeline

Screening ~ 3 weeks3 visits

Treatment ~ Varies

Follow Up ~ at 1-2 weeks post-discharge

Screening ~ 3 weeks

Treatment ~ Varies

Follow Up ~at 1-2 weeks post-discharge

This trial's timeline: 3 weeks for screening, Varies for treatment, and at 1-2 weeks post-discharge for reporting.

Treatment Details

Study Objectives

Study objectives can provide a clearer picture of what you can expect from a treatment.

Primary study objectives

Care Transitions Measure (CTM3)

Secondary study objectives

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

Caregiver information sheet

Patient information sheet

+3 more

Awards & Highlights

No Placebo-Only Group

All patients enrolled in this study will receive some form of active treatment.

Trial Design

2Treatment groups

Experimental Treatment

Active Control

Group I: (Digital Bridge intervention)Experimental Treatment1 Intervention

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.

Group II: ControlActive Control1 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.

0 / 3Eligibility criteria met