Addressing safety, quality and cost of care through a novel, telehealth, outpatient transitional care model – the TTOMMI trial

The intervention in this study will require implementation of a transition coordination service, focusing on the use of nursing transition coordinators, known as ‘STARnurses’ – i.e., nurses that Support Transitions And Referrals. The Stokes’ ‘Foundations Framework' will be used to guide implementation of the intervention to develop and test a transitional model of care (MoC) to optimally support people living with multimorbidity, via telehealth (including telephone), and support continuity of care between the secondary (acute) and primary healthcare sectors to minimise direct contact with hospital services. The STARnurses will receive role and research orientation training on commencement of employment into the STARnurse role. The role is at a Level 2 Registered Nurse, and a Position Description has been designed. Physical or informational materials used in the intervention include: • Participant consent and patient information sheets • Participant health information and folder • Supporting Transitions and Referrals nurse (STARnurse). Information re STARnurse role and Service description • Nursing and other validated assessment tools (e.g., Kessler K 10, ESAS-r, [Edmonton Symptom assessment]GSE & MUST tools • Referral Pathways • Patients will use their own mobile phone or device for telehealth or phone conversations. If no device available to an iPad will be offered. Procedures, activities, and/or processes: • Consent procedure • Nursing, health, and transition assessment with the patient and family/significant other(s) • Transition management and care planning and phone call follow up with the patient and family/significant other(s), GP, practice nurse and service providers/supports • Follow up phone calls with participant, for the purpose of monitoring their condition and progress post-discharge and coordination support services required. Intervention delivery The intervention will be delivered, either over the phone or via teledirect – an interactive online health platform. The mode of delivery: Initial assessment and planning will be face to face. Following discharge, the participant will be followed up via telephone or teledirect. The number of times the intervention will be delivered and over what period of time: The intervention will be delivered once, over a period of 6 – 8 weeks. The location/setting where the intervention occurs: the intervention will be over the phone or online, from the hospital (Supporting Transitions and Referrals nurse [STARnurse]) to the patients’ location (most often at home). Any strategies used to assess or monitor adherence or fidelity to the intervention: Training of the STARnurses to ensure fidelity of assessment and intervention delivery has been provided. This involved a week of orientation and 1 month piloting of the intervention. Similarly, the multidisciplinary team have had education and information regarding the nature of the intervention and their role. When there is multi-D staff turnover (i.e., new interns or registrars) the incumbent staff will handover patients and the STAR nurses and researcher will provide education to new or rotating staff. Intervention fidelity: The Lead investigator (Professor Sepehr Shakib) will review and audit participants’ electronic medical records and data collection for quality and consistency. The STARnurses will be supported and supervised operationally by a Level 3 registered nurse. The trial will be governed by clinical research expert advisory group. The intervention will involve four main stages: Phase 1: In-hospital ‘risk of readmission’ transition screening. This will be delivered by ‘STARnurses’, Transition Coordination nurses who Support Transitions and Referrals for the participants. When participants are identified as ‘high-risk of readmission, the STARnurses will use the following assessment tools to assess the patients’ transition needs: General Nursing Assessment, Barthel Index, Edmonton Frailty scale, ESAS-r assessment, K10 Kessler, MUST scale and GSE. Phase 2: In-hospital patient baseline assessment, more detailed risk of readmission assessment and collaborative development of a Transition Action Plan; Based on the needs identified from the detailed assessment a template transition action plan has been developed that the STAR nurse will complete with and for all participants. The GP will be contacted prior to the patient’s discharge and the transition action plan communicated to them on the patients discharge. Phase 3: Post-discharge from hospital, participants will receive transitional care coordination, with phone calls or telehealth follow up in the first 48 hours following discharge, and then weekly and fortnightly. The purpose of the phone calls will be to monitor participants’ stability ad progress. If the person deteriorates, a pathway has been established to recall the patient to an urgent/immediate care centre for further assessment and management and prevent a hospital admission. The patient has been previously instructed to call the STARnurse if they are feeling unwell, or not progressing (in addition to the routine phone calls). Phase 4: Discharge from the transition service and handover to the general practitioner and practice nurse (primary health care setting). This would require a conversation with the patient and discussion with the Multi-D team to ensure patient is stable in the community and if not stable – follow up care required by GP or others. A phone call and letter to the GP/Practice will summarise the participants’ transition admission, discharge and follow up care required. Usual care is defined as the ‘usual follow up services’ planned whilst the patient is in hospital, prior to discharge. Follow up is not implemented at all post-discharge from the hospital (usual care). However, some services are planned or initiated whilst the participant is in hospital in preparation for post-discharge, but provision of these services is not followed up. These services would include ‘hospital in the home,’ RDNS, rehabilitation or respite services.