Optimising older People's Transition from acute care Into residential aged care through Multidisciplinary Assessment and Liaison (OPTIMAL)

The intervention involves risk stratification and implementation of a customised bundle of interventions for hospitalised older patients who are being discharged to residential aged care for the first time. The study aims to evaluate the implementation and clinical effectiveness of introducing a risk adjusted post-discharge bundle of interventions to support older adults transitioning from hospital to residential aged care for the first time. Previous research from the United States shows that this can significantly reduce preventable readmissions. This approach has previously not been tested in the Australian setting where it is known that 22.6% of individuals who transition to residential aged care for the first time re-present to an emergency department, and 18% will have an unplanned hospitalisation within 90 days. We will conduct a stepped wedge randomised controlled trial with embedded process evaluation across multiple hospital sites in three local health networks (LHN) in South Australia: South Adeliade Local Health Network (SALHN), Central Adelaide Local Health Network (CALHN) and Northern Adelaide Local Health Network (NALHN). Randomisation will be at the level of the LHN. The study population is people aged 65 years and older, discharged from hospital to a residential aged care facility for the first time. We will select up to twelve wards across the selected hospitals in the three LHN. Each LHN will be randomised to either the control or intervention phase, with one LHN per randomisation, and all wards within an LHN will commence the intervention together. Over 14 months, we will enroll 1545 participants across the three LHNs. We will implement the intervention in four steps, with 74 participants per LHN in the first step (establishment phase), and 147 participants per LHN per step in subsequent steps. Data of all eligible patients from the selected hospital wards will be collected until the target sample size is reached. The project budget will fund a nurse facilitator in each LHN, who will be a SALHN/CALHN/NALHN employed clinician having access to hospital electronic records and working and communicating with the ward staff. This position is a Level 3 Registered Nurse, and their role is that of an internal facilitator to ensure that evidence-based practice occurs. The nurse facilitator will have experience working with older people and be familiar with residential care facilities and understand dementia. In the establishment phase: all selected wards will deliver usual care. The data dashboard will be developed and introduced to staff in the LHNs. The discharge note will be implemented and introduced to staff. A nurse facilitator will be appointed to each LHN at least one month prior to the intervention start. The nurse facilitator will work with the clinical teams in each LHN to agree on the evidence bundle of interventions to be implemented for each level of readmission risk. We will carry out pre-implementation context mapping interviews with key decision makers from each LHN and surveys of clinical managers and members of clinical teams. In the intervention phase eligible patients will be stratified based on risk of readmission and the agreed bundle of interventions will be delivered by the LHN team, based on the patient's assessed risk. We will be using a tool developed for this population to stratify patients based on their risk of readmission (1) when they are ready for discharge from the hospital. The tool has been incorporated into a data dashboard which utilises the EMR data (including gender, age, past medical history, prescribed medications (such as warfarin, anticholinergics and proton pump inhibitors), and number of previous hospitalisations and unplanned ED presentations within defined periods), to categorise eligible patients into risk levels. Risk of readmission will be higher in patients who are male, age more than 90 years, having a history of delirium, Dementia, incontinence, on specific medications, hospitalised in the past 30 days or one year, or had unplanned ED presentations in the preceding 30 days. Based on their risk level, individuals will receive a customized post-discharge bundle of interventions. Each LHN will be responsible to select the bundle of evidence-based interventions that will be implemented in their sites (there is no defined number of interventions to be implemented, but the selected interventions should be stratified according to the assessed risk). Interventions may include (1) a post-discharge phone call within 48-72 hours, (2) medication reconciliation by a pharmacist within one week, (3) same-day discharge summaries, (4) access to a geriatric hotline, and (5) a visit from an advanced geriatric practice nurse within seven days. High risk patients may transition service navigator for a month post discharge, while low-risk patients may only receive a timely discharge summary and a phone call. As this is a stepped wedge cluster randomised controlled trial, the length of the intervention phase will be 12 months for LHN 1, 8 months for LHN 2 and 4 months for LHN 3. The LHNs will serve as their own controls. Outcomes will be monitored using the data dashboard. The primary outcome is readmissions within the first 30- and 90-days post-discharge and the secondary outcomes are the length of stay during readmission and the proportion of eligible patients who receive the risk stratified bundle of interventions. Process evaluation will include assessment of the acceptability, adoption, feasibility and fidelity of implementation. We will carry out implementation context-mapping interviews with key decision makers from each LHN and surveys of clinical managers and members of clinical teams. Adherence to the intervention will be assessed through the activity log and field notes maintained by the nurse facilitator. In the post intervention phase, we will monitor outcomes and complete data analysis. We will carry out post implementation context-mapping interviews with key decision makers from each LHN and surveys of clinical managers and members of clinical teams. We will disseminate the results to identified stakeholders and promote translation of findings. The materials that will be used include: - Interview guides for the pre-intervention, intervention and post intervention context mapping interviews. The interview guides are designed to obtain insights on the context in which implementation takes place, with regards to the innovation (what the current practice is and how the intervention is perceived), recipients (who would be involved, their role in implementation, the available capacity and support, additional resources required, and possible challenges), the local context, organisational context and external health system (facilitators and barriers to implementation).. - Survey questionnaire (via Qualtrics) for the pre-intervention, intervention and post intervention context mapping surveys, which is expected to take 15 minutes to complete. - Participant information and consent forms for the interviews and surveys. - Poster to be displayed in participating wards to provide information to patients and families about the study. The poster explains that we are working on improving the quality of transfers to residential care and are tracking the outcomes of patients on this ward to monitor whether they return to hospital. It includes a contact number for the nurse facilitator whom patients and families can contact should they have any queries about the study. - Activity log and field notes to be maintained by nurse facilitator in each LHN, which will contribute to process evaluation Procedures, activities and processes include: - Steering committee meetings. The Steering Committee provides high level oversight and guidance to the project. The Steering Committee meets monthly for a duration of one hour, and comprises the core research team, the implementing leads and team from each LHN. - Project planning workshops with stakeholders, overall and at the LHN level - Development of data dashboard to identify & risk stratify patients and follow up for outcomes - Establishment of LHN implementation committees and regular meetings of committees - Develop LHN specific SOP (procedures for intervention will be decided by each LHN) - Education/training sessions for clinicians on using the data dashboard, the OPTIMAL intervention, and the LHN specific SOP. These sessions will be conducted during the establishment phase, with a duration of one hour each. They will be organised by the nurse facilitator for each LHN, conducted by LHN leads and implementing team, with the support of members of the core research team. The bundle of interventions will be delivered in person or over the phone, as decided by each LHN team. The intensity of the intervention for each level of risk and the person who will deliver the intervention will also be decided by the LHN team. The intervention will take place in the selected hospitals, prior to discharge and in the residential aged care facility. 1. Inacio MC, Jorissen RN, Wesselingh S, Sluggett JK, Whitehead C, Maddison J, et al. Predictors of hospitalisations and emergency department presentations shortly after entering a residential aged care facility in Australia: a retrospective cohort study. BMJ Open. 2021;11(11):e057247.