NCT03157999

Community Assets Supporting Transitions (CAST)

A Pragmatic Effectiveness-implementation Trial to Evaluate a Hospital-to-home Transitional Care Intervention Compared to Usual Care for Older Adults With Multiple Chronic Conditions and Depression

• Status: Completed
• Phase: N/A
• Study type: Interventional
• Enrollment: 127 (actual)
• Sponsor: McMaster University · Academic / Other
• Sex: All
• Age: 65 Years
• Healthy volunteers: Not accepted

Summary

The aim of this study is to test a support program for older adults with symptoms of depression and other chronic health problems after they are discharged home from hospital. The study will be conducted in three communities in Ontario (Sudbury, Burlington, and Hamilton) and the program will be implemented with input from community members. The program will be delivered by a Registered Nurse, who will provide support to patients via home visits and telephone calls. The nurse's role will involve linking patients and their caregivers with needed services and supports, reviewing medications that the patients are taking, assessing patients' health, building the skills of patients in problem-solving and managing their care, and providing education to patients and their caregivers.

Detailed description

Implementing transitional care interventions for older adults with depressive symptoms and multiple chronic conditions (MCC) is a pressing concern since older adults with depression face persistent health disparities. The Community Assets Supporting Transitions (CAST) research team seeks to address these health inequities, and improve health outcomes in this vulnerable and under-served population by developing and implementing an intervention that will improve patients' self-management ability, support their families and caregivers, and build capacity for primary care and other health and non-health providers to collaborate in delivering home and community services. The proposed study builds on our pilot study that evaluated a nurse-led intervention for older adult home care clients with MCC and depressive symptoms and demonstrated that the intervention was feasible and effective in reducing depressive symptoms. The overall aim of the study is to improve care transitions in older adults with MCC and depressive symptoms. The project will address three research questions: 1. What is the effect of a new, nurse-led hospital-to-home transitional care intervention compared to usual care on health outcomes and costs for older adults with MCC and depressive symptoms? 2. How is a care transition intervention adapted and implemented in diverse settings? 3. What is required to sustain and scale up the intervention? We hypothesize that the intervention will improve health outcomes and reduce use of expensive health services compared to usual care at no additional cost, from a societal perspective.

Conditions

• Comorbidity
• Depressive Symptoms

Interventions

Type	Name	Description
BEHAVIORAL	Intervention group (CAST)	Intervention duration is expected to be 6 months. A full-time registered nurse (RN) will function as a Care Transitions Coordinator (CTC) who works collaboratively with one local hospital and other health and non-health representatives to deliver the intervention, which includes: * care coordination and system navigation (including facilitating timely primary care follow-up); * medication management; * assessing the needs and risk of the participants (including in-depth assessment of depressive symptoms); * evidence-based management of depressive symptoms and other chronic conditions to prevent the onset and worsening of other chronic conditions; * patient and caregiver education; and goal setting and problem-solving therapy.

Timeline

• Start date: 2017-07-25
• Primary completion: 2020-06-15
• Completion: 2020-06-15
• First posted: 2017-05-17
• Last updated: 2023-03-23

Locations

4 sites across 1 country: Canada