Active not recruitingNAINTERVENTIONAL

Effectiveness of a Comprehensive Patient-centered Hospital Discharge Planning Intervention for Frail Older Adults

This study is testing a new way to help older, frailer patients when they leave the hospital. Many older people find it hard to do everyday tasks and can end up back in hospital soon after going home. The new plan, called "HOME," has been developed in Australia and is now being adapted for Canada (and this study is a first step to see if it works well). It involves working closely with patients and their families in the hospital, checking their homes before they leave, giving support once they are home, and making follow-up calls. The aim is to help them manage better at home, do more daily activities independently, and reduce the chances of needing to return to hospital.

At a glance

Status

Active not recruiting

Phase

Sponsor

Université de Sherbrooke

Enrolment target

Start

07 Nov 2019

Estimated completion

01 Dec 2025

Frail Older Adults

What is this study about?

When older people, especially those who are a bit frailer, leave the hospital, it can sometimes be a challenge to get back to their usual daily life. They might find it hard to do things they used to, like cooking or getting dressed. Unfortunately, this can sometimes lead to them needing to come back to the hospital sooner than expected.

Researchers are looking into a new and improved way to plan for when these patients go home. This new plan, called "HOME," was first developed in Australia and is now being looked at for use in Canada. The idea behind HOME is to give patients and their families more support and guidance before, during, and after leaving the hospital. This includes talking with them about their goals and any problems they might face, checking their home to make sure it's safe, and offering training and support once they're back in their own environment. They'll even get follow-up phone calls to check in.

The main goal of this study is to see if this new HOME plan can help older, frailer patients do more everyday activities on their own and reduce how often they need to be readmitted to hospital or visit accident and emergency. This particular study is a first step to make sure the plan can be properly tested on a larger scale later on. If it works well, it could really change how hospitals support older patients when they go home.

Key takeaways

A study for frail older adults (70+) leaving hospital.
Tests a new support plan called 'HOME' for returning home.
Aims to improve daily living skills and reduce hospital readmissions.
Involves patients and a family member in the planning process.
Includes home checks and follow-up support after discharge.

Who may be eligible?

This study is looking for volunteers who are 70 years old or older. You should be able to speak and understand either English or French comfortably. It's also important that you're expected to return to live in your own home or community after leaving the hospital.

Patients who have minor issues with memory or thinking (sometimes called mild cognitive impairment) are welcome to take part. This study is designed for those who are expected to stay in hospital for at least five days. Another key part is that a family member must agree to be involved in the study with you, as their support is important for the HOME plan.

If you meet these main points, the researchers would be happy to discuss the study with you further to see if it's a good fit.

Could this study suit you?

Answer these quick questions to see if you may be eligible. This is a guide only — the research team makes the final call.

Are you 70 years old or older?
Do you expect to live at home after hospital?
Are you able to speak and understand English or French?
Do you have a family member who can join the study with you?
Are you expected to stay in hospital for at least 5 days?

Answer every question to see your result.

What does participation involve?

If you take part in this study, the research team will work closely with you and a family member to create a personalised plan for your return home from the hospital. This involves discussions while you're in the hospital to set goals and work through any potential problems you might face. Before you even leave the hospital, someone from the team will visit your home to check for any safety issues and talk about them with you and your family.

Once you're back home, the team will visit again to provide training and support for any ongoing needs. You and your family will also receive follow-up phone calls to see how you're getting on and offer continued support. The total duration of your participation in the study will depend on how long these follow-up elements are needed, but the main focus is around your discharge from hospital and the immediate period afterwards.

Potential risks and benefits

Taking part in this study may offer several potential benefits. It could mean you receive extra support and a more detailed plan for your hospital discharge, which might help you feel more confident and capable of managing at home. This could lead to a smoother recovery and potentially reduce the chance of needing to return to hospital soon after. As this is a research study, there's no guarantee of direct benefit for every participant. The biggest risk is the time commitment required from both you and your family member. There are no medical risks as no new medications or procedures are involved. You are free to withdraw from the study at any time without giving a reason, and your medical care will not be affected.

Locations (1)

CIUSSS de l'Estrie CHUS
Verified postcode
Sherbrooke, Canada

Common questions

What is the 'HOME' intervention?

It's a special plan to help frail older patients prepare for and settle back into their homes after leaving the hospital, with support for them and their families.

Why is this study needed?

It's the first step to test if the 'HOME' plan, which was developed in Australia, can work well and help frail older patients in Canada.

Will I get new medicines if I join?

No, this study is about improving the hospital discharge planning process, not about new medicines.

Who is considered a 'frail older adult' for this study?

The study is looking for people aged 70 or older who might have some difficulties with daily activities and are expected to be in hospital for at least 5 days.

What happens if I change my mind?

You are free to leave the study at any time, and it won't affect your medical care.