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

Area of Science:

• Geriatric Medicine
• Implementation Science
• Healthcare Management

Background:

• Transitions from hospital to home present challenges including poor information flow and patient/caregiver insecurity.
• Existing transitional care models may not adequately address the complexities of geriatric care.
• Developing effective transitional care strategies is crucial for improving patient outcomes and reducing readmissions.

Purpose of the Study:

• To develop and pilot test the AdvantAGE transitional care model within a Swiss geriatric hospital setting.
• To identify and address key challenges in the hospital-to-home transition for elderly patients.
• To create a tailored transitional care model aligned with local healthcare needs and contexts.

Main Methods:

• A multi-method design was employed over three stages from January 2021 to December 2023.
• Contextual analysis utilized the Consolidated Framework for Implementation Research and qualitative interviews.
• The AdvantAGE model was developed, pilot tested on geriatric wards, and refined using a logic model approach with stakeholder input.

Main Results:

• Central challenges identified include insufficient information flow, patient/caregiver insecurity, and poor treatment adherence.
• The AdvantAGE model features five core elements: continuous patient/caregiver support, primary care coordination, home health management, medication/self-management support, and advance care planning.
• A pilot test with 62 patients over 10 months informed model refinement and logic model development.

Conclusions:

• An implementation science approach successfully facilitated the development and refinement of the AdvantAGE transitional care model.
• The study highlights the creation of a context-specific transitional care model, offering valuable insights for practitioners, researchers, and policymakers.
• Findings support the development of improved transitional care practices and policies in geriatric settings.