Optimizing Hospital-to-home Transitions for Older Adults With Stroke and Multimorbidity (NCT04278794) | Clinical Trial Compass
CompletedNot Applicable
Optimizing Hospital-to-home Transitions for Older Adults With Stroke and Multimorbidity
Canada90 participantsStarted 2020-11-30
Plain-language summary
Stroke is the leading cause of death and adult disability in Canada. Sixty percent of these older adults (\> 65 years) will return to their homes after a stroke and will require ongoing rehabilitation. About 92% of older adults have two or more chronic conditions. These patients often require services from a number of providers in a number of settings and are therefore, susceptible to fragmented health care when transitioning from hospital to home. New interventions are needed to improve the quality of care as patients move from hospital to home after a stroke. The proposed research project will examine the impact of a new intervention on patient/caregiver health, patient/caregiver and provider experience and costs, compared to usual health care services. The new intervention will be coordinated by a system navigator and consists of four core components: 1) development of a comprehensive discharge plan, 2) up to 6 home visits (supported by phone calls) by an interprofessional outpatient team, 3) monthly case conferences including the interprofessional care team who will discuss and focus on the patient's goals and care needs, and 4) linkages to other healthcare and community services. This multidisciplinary project will build on our previous study, which provided the groundwork for further study of this new intervention.
Who can participate
Age range
55 Years
Sex
ALL
See this in plain English?
AI-rewrites the medical criteria so a patient or caregiver can understand them. Always confirm with the trial site.
Inclusion Criteria:
* age 55 years or greater
* hospitalized for stroke and receiving in-patient rehabilitation
* diagnosed with at least 2 or more chronic conditions
* will be discharged to the community from in-patient rehabilitation (not hospital or long-term care)
* not planning to move out of the study catchment area in the next 6 months
* referred to outpatient stroke rehabilitation services
* capable of providing informed consent, or have a substitute decision-maker who is capable and able to provide informed consent on his/her behalf
* competent in English, or has an interpreter who is competent in English
Exclusion Criteria:
* less than 55 years of age
* fewer than two chronic conditions
* planned discharge to hospital or long-term care facility
* cognitively impaired with no substitute decision maker who is capable to provide consent
* not competent in English with no interpreter
Questions worth asking your doctor
Bring these to your next appointment. They're a starting point for a shared conversation — not a sign you qualify or a recommendation to enrol.
1Based on my diagnosis and history, is this trial worth exploring for me — or is there a standard treatment we should try first?
2What does this trial's phase tell us about how much is already known about its safety and benefit?
3What would taking part actually involve for me — visits, tests, time, and travel?
4What are the known and possible risks or side effects I should weigh, and how would they be monitored?
5If this trial isn't the right fit, what other options or trials would you suggest I look into?
Generated to help you prepare — always confirm anything about your own eligibility and care with the study team and your doctor.
Questions for the trial coordinator
The trial coordinator is the person who runs the study day to day. These cover the practical side — logistics, costs, and what taking part would actually mean for your life. The study team confirms whether you meet the criteria; these are questions to ask, not a sign you qualify.
1What does taking part actually involve week to week — how many visits, where, and how long does each one take?
2What costs are covered by the study, and what might I have to pay for myself, including travel, parking, or time off work?
3What happens during screening, and what happens if the study team confirms I don't meet the criteria after those tests?
4Who pays for the scans, blood work, and other tests the trial requires — the study, my insurance, or me?
5How will being in the trial affect my regular care, and will my own doctor stay informed and involved?
6Can I leave the trial at any point if I change my mind, and what would happen to my care if I do?
A starting point for the conversation — always confirm anything about your own eligibility, costs, and care with the study team and your doctor.
What they're measuring
1
Any hospital readmission for any cause within 6 months