Transitional care from skilled nursing facilities to home: study protocol for a stepped wedge cluster randomized...

Area of Science:

• Gerontology
• Health Services Research
• Palliative Care

Background:

• Skilled nursing facility (SNF) patients are medically complex with high rates of mortality or acute care use post-discharge.
• Transitional care for these patients and their caregivers is often inadequate, failing to prepare them for managing serious illnesses at home.

Purpose of the Study:

• To test the efficacy of the Connect-Home transitional care intervention for seriously ill SNF patients and their caregivers.
• To evaluate the intervention's impact on patient and caregiver preparedness, quality of life, functional status, acute care use, and caregiver burden.

Main Methods:

• A stepped wedge cluster randomized trial involving six SNFs in North Carolina, USA.
• The Connect-Home intervention includes SNF staff creating a Transition Plan of Care and a nurse implementing it at home.
• Primary outcomes: patient and caregiver preparedness; Secondary outcomes: quality of life, functional status, acute care use, caregiver burden and distress. (N=360 patients, N=360 caregivers)

Main Results:

• The study is designed to detect an 18% increase in patient preparedness for discharge score.
• Linear mixed models will compare outcomes between intervention and usual care periods.

Conclusions:

• The Connect-Home intervention, utilizing existing clinical staff, aims to improve transitional care for SNF patients and caregivers.
• The study will assess the intervention's ability to prevent avoidable acute care use and advance transitional care science in palliative care.
• Protocol modifications were made to mitigate COVID-19 related risks.