NCT02854826

Systems Addressing Frail Elders (SAFE) Care Implementation

• Status: Completed
• Phase: —
• Study type: Observational
• Enrollment: 330 (actual)
• Sponsor: Cedars-Sinai Medical Center · Academic / Other
• Sex: All
• Age: 18 Years – 110 Years
• Healthy volunteers: Not accepted

Summary

Systems Addressing Frail Elders (SAFE) Care is a nurse-led interprofessional team model to rapidly identify and provide safe and effective inpatient care to high risk older adults and help support their successful transition back to the community. Developed and demonstrated to be effective in one hospital - the model is now being disseminated and studied in three additional hospitals (multiple organizational case study).

Detailed description

Three Magnet hospitals in Los Angeles County (Huntington Hospital, Torrance Memorial Medical Center and Ronald Reagan UCLA Health System) are collaborating on this demonstration and evaluation project (Multiple Case-Study Design). The project will engage interprofessional hospital leadership; provide training and coaching in implementation processes of the SAFE Care model; and track outcome of the SAFE Care model as implemented in the three collaborating site hospitals (three case studies). The investigators hope to contribute to the existing state of the science in dissemination and implementation of evidenced-based innovations. The collective data from the three sites (collected through interviews with hospital leadership and staff and with de-identified patient data on program implementation outcomes) will provide information about the effectiveness of the implementation process and support further dissemination.

Conditions

• Frail Older Adutls

Interventions

Type	Name	Description
OTHER	SAFE Care model of care	SAFE Care Model Site Intervention: 1. Endorse best practices for frail patients; 2. Identify frail patients promptly using multi-dimensional screening and assessments; 3. Employ interprofessional unit-based care team approach to frailty risk reduction during inpatient stay and create post-acute care transitions (PACT) plan recommendations; 4. Develop electronic health record templates for patient-centered interprofessional frailty notes; 5. Communicate PACT plans to primary care providers to promote safe transitions to the ambulatory setting and across the continuum of care. 6. Increase awareness, improve management of frailty, and improve overall health and well-being for adults who are frail or at risk of becoming frail.

Timeline

• Start date: 2016-07-01
• Primary completion: 2018-07-27
• Completion: 2018-07-27
• First posted: 2016-08-04
• Last updated: 2018-08-31