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HELSEVEL-H-Gode og effektive helse-, omsorgs- og velferdstjenester

From Knowledge to Action (K2A): Developing interventions to improve older adult care transitions between nursing homes and emergency wards

Alternative title: Fra kunnskap til handling: Utvikling av intervensjoner for forbedring av pasientoverføringer mellom sykehjem, legevakt og akuttmottak

Awarded: NOK 16.0 mill.

The main objective of the K2A project is improved practices related to care transfers between nursing homes and emergency wards (both municipal and hospital based), focusing on 1. which care transfers are potentially avoidable, and 2. when necessary, how could they possibly work best for the nursing home patients. Care transfers potentially implies severe risks and suffering for frail older people, and many patients experience serious consequences related to their physical and/or mental health. Close to 60 % of Norwegian nursing home patients are transferred to hospitals each year, and more than 20 % of them are re-admitted to hospitals within 30 days. International research findings indicate that around half of hospital transfers are avoidable. In order to achieve objective, our multidisciplinary team will employ a mixed-methods approach first to engage with various providers, planners and patients to understand the nature of problematic care transfers from their various perspectives (WP1), second to quantify using registry data the various patterns and costs associated with transitional care (WP2), and using this collective knowledge, third to collaborate with stakeholders to plan and pilot test interventions that align with daily care routines and hence have strong sustainment and scale potential (WP3). The partnership of the project consists of Centre for Care Research, Western Norway, at Western Norway University of Applied Sciences (project leader), The National Centre for Emergency Primary Health Care (NKLM, NORCE), NORCE Society, University of Manitoba, Canada, Bergen Municipality, and Sunnfjord and Ytre Sogn A & E Clinic.

Knowlegde to action (K2A) proposes an international (Norway and Canada) multidisciplinary research in where the researchers cooperate with healthcare planners, providers and patients who have agreed to collaborate to improve older adult care transitions between nursing homes and emergency wards (municipal and hospital based). Our primary objective is to develop and field test best-practice and contextualized interventions to improve care transitions between nursing homes and emergency wards and to develop an evidence-based model to guide practices related to the care transfers. While these interventions apply directly to Norwegian residents, the knowledge gained will have significant international implications, stemming from our nuanced and context sensitive research approach. Our team will employ a mixed-methods approach first to engage with various providers, planners and patients to understand the nature of problematic care transfers from their various perspectives (WP1), second to quantify using registry data the various patterns and costs associated with transitional care (WP2), and using this collective knowledge, third to collaborate with stakeholders to plan and pilot test interventions that align with daily care routines and hence have strong sustainment and scale potential (WP3). Researchers internationally state that about half of all nursing home to hospital transitions are potentially unwarranted and/or problematic, and place residents at increasing risk without significantly improving their clinical course. Strategies to improve these transitions are urgently needed for the most medically complex and frailest segment of our population, most of whom cannot advocate for themselves. Creating and sustaining these strategies requires teams with the collective skills to develop, conduct and evaluate meaningful change solutions, in ways that facilitate their sustainment and scale.

Activity:

HELSEVEL-H-Gode og effektive helse-, omsorgs- og velferdstjenester