AdvantAGE: Implementation and Evaluation of an Interprofessional Transitional Care Model for Frail Older...

To implement and evaluate an Advanced Practice Nurse-led transitional care model (AdvantAGE) to reduce rehospitalisation rates in frail older adults discharged from a Swiss geriatric hospital.

The study adopts an effectiveness-implementation hybrid design (Type 1) to simultaneously evaluate the effectiveness of the care model and explore the implementation process.

The primary outcome, the 90-day rehospitalisation rate, will be evaluated using a matched-cohort design with a prospective intervention group and a retrospective control group. Secondary outcomes include the number of emergency department visits, health-related quality of life and intervention costs. The care model was developed through comprehensive contextual analysis and pilot testing in an iterative approach. It comprises five core elements: continuous support, care coordination, comprehensive health management at home, medication and self-management and advance care planning. Data collection includes both quantitative and qualitative methods, utilising routine hospital data, structured and semi-structured interviews and observations. Qualitative data will provide insights into implementation outcomes, potential barriers and facilitators. Additionally, a process evaluation will offer an in-depth understanding of individual intervention effects and reasons for rehospitalisation.

The AdvantAGE project, grounded in implementation science methodology, aims to significantly improve transitional care outcomes for frail older adults. The results are expected to provide essential recommendations for scaling up the model to other settings.

The study addresses the issue of frequent rehospitalisations in older adults, which carry risks of functional and cognitive decline. By implementing a comprehensive transitional care model, the study aims to improve continuity of care, reduce readmissions and enable frail older adults to remain in the community longer. The project highlights the importance of contextually adapted intervention and implementation strategies to bridge the gap between research and real-world healthcare practice.

The project employs a participatory approach, engaging representatives from the hospital and primary care settings, the cantonal health department and older people and their caregivers.

This study has been registered at clinicaltrials.gov on 5 January 2024 (Identifier: NCT06190288).