Study targets care after hospital discharge
Researchers will test the effectiveness of the Living Well after Hospital program, which includes a dedicated transitional care nurse, personalised discharge planning, educational modules, and support for linking with community-based services.
A University of Newcastle and Hunter New England Health collaboration will test the effectiveness of a coordinated transitional care program to support older adults and their support persons during the 90 days following discharge from hospital.
The program – Living Well after Hospital – includes a dedicated transitional care nurse, personalised discharge planning, educational modules, and support for linking with community-based services.
The randomised controlled trial will involve 940 older adults plus their nominated support person as a main source of practical or emotional support during their recovery at home.
The study aims to increase the amount of time that older adults can remain living at home following hospital discharge and optimise their quality of life, said lead researcher Dr Elise Mansfield.
“Older adults with complex care needs are at high risk of adverse events following hospital admission, including readmissions to hospital, placement in a residential aged care facility, and death.
“There is a need to find innovative solutions to reduce the likelihood of these events and ensure patients regain their quality-of-life following discharge,” Dr Mansfield told Community Care Review.
“This study will determine whether a multi-component support package is successful in helping older adults remain living in the community for as long as possible following hospital discharge.”
The study is for community-dwelling people aged 65 and over who are returning home after a hospital stay. It will focus on older people with complex care needs who could benefit from extra guidance and coordination as they return to everyday life.
Each older adult–support person pair will be randomly assigned to either the coordinated transitional care program or usual care.
Recruitment is expected to begin later this year. Each participant will be followed for 90 days after leaving hospital, with the study looking at a range of outcomes including time spent out of hospital, quality of life, confidence in managing health – for both the older person and their support person – and use of healthcare services.
“If found to be effective, adoption of this intervention Australia-wide may reduce the demand on home aged care services to provide support during this transitional period,” Dr Mansfield told CCR.
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