PMID- 33237037
OWN - NLM
STAT- PubMed-not-MEDLINE
LR  - 20240330
IS  - 1929-0748 (Print)
IS  - 1929-0748 (Electronic)
IS  - 1929-0748 (Linking)
VI  - 9
IP  - 11
DP  - 2020 Nov 25
TI  - 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.
PG  - e20220
LID - 10.2196/20220 [doi]
LID - e20220
AB  - 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.
CI  - (c)Carolyn Steele Gray, Terence Tang, Alana Armas, Mira Backo-Shannon, Sarah 
      Harvey, Kerry Kuluski, Mayura Loganathan, Jason X Nie, John Petrie, Tim Ramsay, 
      Robert Reid, Kednapa Thavorn, Ross Upshur, Walter P Wodchis, Michelle Nelson. 
      Originally published in JMIR Research Protocols 
      (http://www.researchprotocols.org), 25.11.2020.
FAU - Steele Gray, Carolyn
AU  - Steele Gray C
AUID- ORCID: 0000-0002-2146-0001
AD  - Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum 
      Research Institute, Sinai Health System, Toronto, ON, Canada.
AD  - Institute for Health Policy, Management and Evaluation, Dalla Lana School of 
      Public Health, University of Toronto, Toronto, ON, Canada.
FAU - Tang, Terence
AU  - Tang T
AUID- ORCID: 0000-0002-1735-7298
AD  - Institute for Better Health, Trillium Health Partners, Toronto, ON, Canada.
AD  - Department of Family and Community Medicine, University of Toronto, Toronto, ON, 
      Canada.
FAU - Armas, Alana
AU  - Armas A
AUID- ORCID: 0000-0002-7664-3294
AD  - Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum 
      Research Institute, Sinai Health System, Toronto, ON, Canada.
FAU - Backo-Shannon, Mira
AU  - Backo-Shannon M
AUID- ORCID: 0000-0002-9758-5580
AD  - Clinical, Health System Strategy, Integration and Planning, Ontario Health 
      (Central Region), Mississauga Halton Local Health Integration Network, Toronto, 
      ON, Canada.
FAU - Harvey, Sarah
AU  - Harvey S
AUID- ORCID: 0000-0002-6310-5315
AD  - QoC Health Inc, Toronto, ON, Canada.
FAU - Kuluski, Kerry
AU  - Kuluski K
AUID- ORCID: 0000-0002-6377-6653
AD  - Institute for Health Policy, Management and Evaluation, Dalla Lana School of 
      Public Health, University of Toronto, Toronto, ON, Canada.
AD  - Institute for Better Health, Trillium Health Partners, Toronto, ON, Canada.
FAU - Loganathan, Mayura
AU  - Loganathan M
AUID- ORCID: 0000-0001-9754-4175
AD  - Department of Family and Community Medicine, University of Toronto, Toronto, ON, 
      Canada.
AD  - Mount Sinai Academic Family Health Team, Toronto, ON, Canada.
FAU - Nie, Jason X
AU  - Nie JX
AUID- ORCID: 0000-0002-9359-3938
AD  - Institute for Better Health, Trillium Health Partners, Toronto, ON, Canada.
FAU - Petrie, John
AU  - Petrie J
AUID- ORCID: 0000-0002-7400-9134
AD  - Institute for Better Health, Trillium Health Partners, Toronto, ON, Canada.
FAU - Ramsay, Tim
AU  - Ramsay T
AUID- ORCID: 0000-0001-8478-8170
AD  - Ottawa Methods Centre, Ottawa Hospital Research Institute, The Ottawa Hospital, 
      Ottawa, ON, Canada.
AD  - School of Epidemiology, Public Health and Preventative Medicine, University of 
      Ottawa, Ottawa, ON, Canada.
FAU - Reid, Robert
AU  - Reid R
AUID- ORCID: 0000-0002-9008-6375
AD  - Institute for Better Health, Trillium Health Partners, Toronto, ON, Canada.
FAU - Thavorn, Kednapa
AU  - Thavorn K
AUID- ORCID: 0000-0003-4738-8447
AD  - Ottawa Methods Centre, Ottawa Hospital Research Institute, The Ottawa Hospital, 
      Ottawa, ON, Canada.
AD  - School of Epidemiology, Public Health and Preventative Medicine, University of 
      Ottawa, Ottawa, ON, Canada.
FAU - Upshur, Ross
AU  - Upshur R
AUID- ORCID: 0000-0003-1128-0557
AD  - Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum 
      Research Institute, Sinai Health System, Toronto, ON, Canada.
AD  - Department of Family and Community Medicine, University of Toronto, Toronto, ON, 
      Canada.
FAU - Wodchis, Walter P
AU  - Wodchis WP
AUID- ORCID: 0000-0003-2494-7031
AD  - Institute for Health Policy, Management and Evaluation, Dalla Lana School of 
      Public Health, University of Toronto, Toronto, ON, Canada.
AD  - Institute for Better Health, Trillium Health Partners, Toronto, ON, Canada.
FAU - Nelson, Michelle
AU  - Nelson M
AUID- ORCID: 0000-0003-2002-0298
AD  - Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum 
      Research Institute, Sinai Health System, Toronto, ON, Canada.
AD  - Institute for Health Policy, Management and Evaluation, Dalla Lana School of 
      Public Health, University of Toronto, Toronto, ON, Canada.
AD  - March of Dimes Canada, Toronto, ON, Canada.
LA  - eng
SI  - ClinicalTrials.gov/NCT04287192
PT  - Journal Article
DEP - 20201125
PL  - Canada
TA  - JMIR Res Protoc
JT  - JMIR research protocols
JID - 101599504
PMC - PMC7725647
OTO - NOTNLM
OT  - care transitions
OT  - co-design
OT  - digital health technology
OT  - hospital
OT  - multimorbidity
OT  - pragmatic trial
OT  - primary care
COIS- Conflicts of Interest: None declared.
EDAT- 2020/11/26 06:00
MHDA- 2020/11/26 06:01
PMCR- 2020/11/25
CRDT- 2020/11/25 12:15
PHST- 2020/05/13 00:00 [received]
PHST- 2020/09/13 00:00 [accepted]
PHST- 2020/08/10 00:00 [revised]
PHST- 2020/11/25 12:15 [entrez]
PHST- 2020/11/26 06:00 [pubmed]
PHST- 2020/11/26 06:01 [medline]
PHST- 2020/11/25 00:00 [pmc-release]
AID - v9i11e20220 [pii]
AID - 10.2196/20220 [doi]
PST - epublish
SO  - JMIR Res Protoc. 2020 Nov 25;9(11):e20220. doi: 10.2196/20220.