Care transitions are the movement of a person from one healthcare setting to another. Older adults who
require skilled home health care (SHHC) services (e.g., home-based nursing) after hospital discharge are at
high risk of experiencing early re-hospitalization. SHHC agencies need strategies to ensure safe transitions,
yet there is relatively little research to guide improvement efforts. The goal of the current proposal is to
develop tools to allow SHHC agencies to identify and act upon threats to older adults' safety in real time.
Specific Aim 1: Analyze threats to older adult safety during hospital-to-SHHC transitions through a
prospective cohort study. 1a: Describe the incidence of threats to older adults' safety (as measured by the
Index of SHHC Transition Quality applied to the transitions of recently hospitalized older adults) and identify
strategies for improvement from the perspectives of SHHC providers, older adults, and informal caregivers. 1b:
Compare threats identified by SHHC providers versus older adults'/caregivers' Index responses. 1c: Identify
which Index threats are drivers of suboptimal outcomes: (1) 30-day emergency department (ED) use or re-
hospitalization; (2) older adult/caregiver/SHHC provider transition experience; (3) timely resolution of
medication issues; and (4) mortality.
Specific Aim 2: Refine a bundle of interventions through stakeholder engagement. Guided by a
participatory ergonomics approach, we will form intervention refinement teams (IRTs) including older
adults/caregivers, SHHC providers, and SHHC leadership at two large SHHC agencies. In preparation for pilot
testing of the bundle of interventions, IRTs will meet to (1) present key drivers of suboptimal outcomes (from
SA1) to prioritize areas for SHHC performance improvement, (2) identify system constraints and design
requirements for the bundle, (3) present and select strategies for inclusion in the bundle, (4) evaluate workflow
and assign roles for implementation of the bundle, and (5) anticipate barriers and brainstorm solutions.
Specific Aim 3: Pilot test bundle implementation in a second prospective cohort study to test
feasibility. We will use the Index to identify older adults experiencing high-risk hospital-to-SHHC transitions
and deliver the bundle to these older adults. We will investigate 30-day ED use, re-hospitalization, and
mortality for the intervention group and compare to concurrent and historical controls. IRTs will meet to assess
the impact of the bundle as assessed through surveys and focus groups of older adults/caregivers and SHHC
providers discussing (1) acceptability, (2) appropriateness, (3) identification of barriers to implementation, and
(4) analysis of impact on workflow, including unanticipated consequences.
Completion of these aims will result in tools to improve the quality of older adults' hospital-to-SHHC transitions.
Study findings will build the foundation for future work, including a randomized-controlled-trial testing the
bundle in a broader population of older adults receiving SHHC services after hospital discharge.
