Transitional care from skilled nursing facilities to home: study protocol for a stepped wedge cluster randomized trial

Abstract

Background Skilled nursing facility (SNF) patients are medically complex with multiple, advanced chronic conditions. They are dependent on caregivers and have experienced recent acute illnesses. Among SNF patients, the rate of mortality or acute care use is over 50% within 90 days of discharge, yet these patients and their caregivers often do not receive the quality of transitional care that prepares them to manage serious illnesses at home. Methods The study will test the efficacy of Connect-Home, a successfully piloted transitional care intervention targeting seriously ill SNF patients discharged to home and their caregivers. The study setting will be SNFs in North Carolina, USA, and, following discharge, in patients’ home. Using a stepped wedge cluster randomized trial design, six SNFs will transition at randomly assigned intervals from standard discharge planning to the Connect-Home intervention. The SNFs will contribute data for patients (N = 360) and their caregivers (N = 360), during both the standard discharge planning and Connect-Home time periods. Connect-Home is a two-step intervention: (a) SNF staff create an individualized Transition Plan of Care to manage the patient’s illness at home; and (b) a Connect-Home Activation RN visits the patient’s home to implement the written Transition Plan of Care. A key feature of the trial includes training of the SNF and Home Care Agency staff to complete the transition plan rather than using study interventionists. The primary outcomes will be patient preparedness for discharge and caregiver preparedness for caregiving role. With the proposed sample and using a two-sided test at the 5% significance level, we have 80% power to detect a 18% increase in the patient’s preparedness for discharge score. We will employ linear mixed models to compare observations between intervention and usual care periods to assess primary outcomes. Secondary outcomes include (a) patients’ quality of life, functional status, and days of acute care use and (b) caregivers’ burden and distress. Discussion Study results will determine the efficacy of an intervention using existing clinical staff to (a) improve transitional care for seriously ill SNF patients and their caregivers, (b) prevent avoidable days of acute care use in a population with persistent risks from chronic conditions, and (c) advance the science of transitional care within end-of-life and palliative care trajectories of SNF patients and their caregivers. While this study protocol was being implemented, the COVID-19 pandemic occurred and this protocol was revised to mitigate COVID-related risks of patients, their caregivers, SNF staff, and the study team. Thus, this paper includes additional material describing these modifications. Trial registration ClinicalTrials.gov NCT03810534. Registered on January 18, 2019.

The role of assessment in competence-based gerontological advanced practice nursing

“…More information including groundbreaking research, practice, and policy implications may be found at https:// www.nursing.upenn.edu/ncth/transitional-care-model. Some ongoing trials are testing the program effectiveness (10,11) .…”

“…All these models of care (8)(9)(10)(11)(12)(13)(14)(15) are associated with better health-related outcomes regarding both quality and effectiveness of health care. This success depends on the whole structure of the programs and also on the role of GAPNs.…”

El papel de la evaluación en la enfermería de práctica avanzada gerontológica basada en competencias

“…Se puede encontrar más información, incluida la investigación innovadora, las prácticas y las implicaciones para las políticas de atención en "https://www.nursing.upenn.edu/ ncth/transitional-care-model". Algunas pruebas actualmente prueban la efectividad del programa (10,11) .…”

“…Todos estos modelos de cuidado (8)(9)(10)(11)(12)(13)(14)(15) están asociados a mejores resultados en salud, tanto en la calidad como en la eficacia del cuidado. Este éxito depende de toda la estructura de los programas y del papel de los GAPN.…”

%CRTFASTGEEPWR: a SAS macro for power of the generalized estimating equations of multi-period cluster randomized trials with application to stepped wedge designs

“…This article implements a comprehensive, analytical power method for both complete and incomplete SW-CRTs. The proposed GEE power procedure is motivated by the Connect-Home trial, which uses an incomplete, cross-sectional stepped wedge design to test an intervention to improve outcomes for rehabilitation patients transitioning from skilled nursing facilities (SNFs) to home-based care [Toles et al, 2021]. The primary component of the intervention is an individualized Transition Plan of Care that SNF staff create to support the patient and caregiver at home.…”