Building a Digital Bridge to Support Patient-Centered Care Transitions From Hospital to Home for Older Adults With Complex Care Needs: Protocol for a Co-Design, Implementation, and Evaluation Study

Abstract

Background Older adults with multimorbidity and complex care needs (CCN) are among those most likely to experience frequent care transitions between settings, particularly from hospital to home. Transition periods mark vulnerable moments in care for individuals with CCN. Poor communication and incomplete information transfer between clinicians and organizations involved in the transition from hospital to home can impede access to needed support and resources. Establishing digitally supported communication that enables person-centered care and supported self-management may offer significant advantages as we support older adults with CCN transitioning from hospital to home. Objective This protocol outlines the plan for the development, implementation, and evaluation of a Digital Bridge co-designed to support person-centered health care transitions for older adults with CCN. The Digital Bridge builds on the foundation of two validated technologies: Care Connector, designed to improve interprofessional communication in hospital, and the electronic Patient-Reported Outcomes (ePRO) tool, designed to support goal-oriented care planning and self-management in primary care settings. This project poses three overarching research questions that focus on adapting the technology to local contexts, evaluating the impact of the Digital Bridge in relation to the quadruple aim, and exploring the potential to scale and spread the technology. Methods The study includes two phases: workflow co-design (phase 1), followed by implementation and evaluation (phase 2). Phase 1 will include iterative co-design working groups with patients, caregivers, hospital providers, and primary care providers to develop a transition workflow that will leverage the use of Care Connector and ePRO to support communication through the transition process. Phase 2 will include implementation and evaluation of the Digital Bridge within two hospital systems in Ontario in acute and rehab settings (600 patients: 300 baseline and 300 implementation). The primary outcome measure for this study is the Care Transitions Measure–3 to assess transition quality. An embedded ethnography will be included to capture context and process data to inform the implementation assessment and development of a scale and spread strategy. An Integrated Knowledge Translation approach is taken to inform the study. An advisory group will be established to provide insight and feedback regarding the project design and implementation, leading the development of the project knowledge translation strategy and associated outputs. Results This project is underway and expected to be complete by Spring 2024. Conclusions Given the real-world implementation of Digital Bridge, practice changes in the research sites and variable adherence to the implementation protocols are likely. Capturing and understanding these considerations through a mixed-methods approach will help identify the range of factors that may influence study results. Should a favorable evaluation suggest wide adoption of the proposed intervention, this project could lead to positive impact at patient, clinician, organizational, and health system levels. Trial Registration ClinicalTrials.gov NCT04287192; https://clinicaltrials.gov/ct2/show/NCT04287192 International Registered Report Identifier (IRRID) PRR1-10.2196/20220

How digital health solutions align with the roles and functions that support hospital to home transitions for older adults: a rapid review study protocol

“…These search terms will be partly informed by previous reviews. 17 86 The search will be limited to high income countries because the purpose of this review is to inform future digital health interventions, such as the Digital Bridge intervention, 46 which will be applied in a high income country. 87 We will also limit the search to older adult populations as we anticipate that digital health technologies not tested with older adults may not meet their needs.…”

“…These recommendations will first be applied to the Digital Bridge intervention. 46 These recommendations will be shared with the Digital Bridge research team and patient advisory committees of the two multisite healthcare institutions which are planned sites for the Digital Bridge intervention. A report that highlights key recommendations will be generated to guide the design of the Digital Bridge intervention.…”

“…The Digital Bridge (ClinicalTrials.gov ID: NCT04287192) 46 is an upcoming digital health intervention that our research team is working on, which aims to improve communication across clinical settings. Digital Bridge will be designed with input from multiple intended users (ie, patients, caregivers, hospital clinicians and primary care clinicians) 46 as well as the evidence generated from this review.…”

“…Moreover, we will identify gaps and new opportunities for digital health solutions and platforms to support and facilitate current roles and functions involved in these transitions using a structured rapid review; these gaps and opportunities will be addressed in the design of the Digital Bridge. 46 A structured rapid review is appropriate to produce timely results 66 that will inform how digital technologies can effectively support transitions while informing future development work, as well as areas where the design can be improved. Therefore, the specific objectives of this rapid review include the following: (1) to elucidate the various roles and functions that have been developed to support hospital to home transition of care, (2) to identify existing digital health solutions that support hospital to home transitions of care, (3) to identify gaps and new opportunities where digital health solutions can support these roles and functions and (4) to create recommendations that will inform the design and structure of future digital health interventions that support hospital to home transitions of care for older adults, such as the Digital Bridge intervention.…”

“…Therefore, the specific objectives of this rapid review include the following: (1) to elucidate the various roles and functions that have been developed to support hospital to home transition of care, (2) to identify existing digital health solutions that support hospital to home transitions of care, (3) to identify gaps and new opportunities where digital health solutions can support these roles and functions and (4) to create recommendations that will inform the design and structure of future digital health interventions that support hospital to home transitions of care for older adults, such as the Digital Bridge intervention. 46 …”