A Multi-Method Study to Develop and Pilot Test an Interprofessional Transitional Care Model for Frail Older Adults -...

To develop and pilot test the AdvantAGE transitional care model at a Swiss geriatric hospital.

Multi-method design.

The study progressed in three stages from January 2021 to December 2023: (1) contextual analysis using the Consolidated Framework for Implementation Research, incorporating qualitative interviews, (2) development and pilot testing of transitional care interventions on three acute geriatric wards using a descriptive explorative study design and (3) development and validation of a logic model using an iterative approach involving project interest groups and researchers.

We identified central challenges and needs related to transitions from hospital to home, including insufficient information flow, patient and caregiver insecurities and lacking adherence to recommended treatment. The newly developed transitional care model comprised five core elements: continuous support for patients and caregivers, care coordination with primary care providers, comprehensive health management at home, medication- and self-management with patients and caregivers and advance care planning. Of 137 eligible patients, 62 participated in the 10-month pilot test of the preliminary transitional care intervention, with an average participation duration of 69 days. Findings from the pilot informed the refinement of the intervention elements and the development of a preliminary logic model.

Employing an implementation science approach facilitated the development and refinement of the AdvantAGE model, ensuring alignment with the needs of project interest groups and the specific implementation context.

This study demonstrates the development of a transitional care model tailored to the specific needs and circumstances of the local healthcare context. Findings provide valuable insights for healthcare practitioners, researchers and policymakers, offering implications for developing transitional care practices and policies.

Limited patient and public involvement was incorporated, focusing on the interpretation of the findings of the first step of this study. Further contributions included providing feedback on the development of the elements of the AdvantAGE transitional care model, ensuring the research addressed priorities relevant to patients and primary health care providers in Basel-Stadt.