Transitioning back home after a stay in hospital is a major risk factor for depression, particularly for seniors with multiple chronic conditions (MCC) and few social supports. They may receive limited follow-up care, resulting in medication errors, readmission to hospital, reduced quality of life and higher costs to the health care system.
Researchers in the Aging, Community and Health Research Unit (ACHRU), part of the School of Nursing at McMaster University, received a $1 million IMPACT award for Home and Community Care to develop and evaluate a new hospital-to-home transitional care intervention for older adults with chronic health problems and depression.
The study will be led by Dr. Maureen Markle-Reid, co-scientific director of the ACHRU and Canada Research Chair in Aging, Chronic Disease and Health Promotion Interventions, and Dr. Carrie McAiney, Associate Professor in the Department of Psychiatry and Behavioural Neurosciences at McMaster University and head of Senior Mental Health Research at St. Joseph's Healthcare.
The IMPACT awards, funded by the Ontario SPOR SUPPORT UNIT (OSSU), are designed to bring together diverse stakeholders – patients, clinicians, researchers, policy makers, knowledge users, industry and other health sector participants – to develop promising research opportunities that improve integrated care strategies, patient health outcomes and advance the health system.
These strategic awards are directly aligned with Ontario's Action Plan for Health Care announced by Health Minister Eric Hoskins in February.
The intervention designed by ACHRU researchers will involve 216 older adults, 65 years of age and older with depression and at least two additional chronic health problems, who have been discharged from hospital to home and live in three diverse LHIN (Local Health Integration Network) communities in Ontario: Northern Ontario, Hamilton Niagara Haldimand and Brant and Mississauga-Halton. Patients, caregivers, providers and researchers will work side-by-side in the design of the intervention and its testing.
The intervention includes home visits, telephone follow-up and nurse-led co-ordination. Researchers will track outcomes for hospitalizations, length of stay, emergency department visits, psychiatric hospitalizations, home care, family doctor and specialists visits and drugs. Effects and costs of this hospital-to-home support program will be evaluated.
Markle-Reid said this research project will not only support older adults to age successfully at home. It will also build a solid foundation for transforming the health care system to support patient-centred care, the integration of health and non-health professionals, agencies and other sectors while reducing health care costs, she said.
"This funding provides an opportunity to make a real difference for older adults living with depression, and other chronic conditions, by identifying how transitions from hospital can occur safely and successfully," said McAiney.
The aim of the ACHRU is to promote optimal aging at home for older adults with MCC and to support their family caregivers through the design and evaluation of innovative inter-professional community-based interventions.
The Ontario SPOR SUPPORT UNIT is a collaboration across 12 leading Ontario research centres. It is jointly funded by the Ontario government and the Canadian Institutes of Health Research (CIHR) to implement Canada's Strategy for Patient-Oriented Research within Ontario.