Implementation of the Community Assets Supporting Transitions (CAST) transitional care intervention for older adults with multimorbidity and depressive symptoms: A qualitative descriptive study.

Background: Older adults with multimorbidity experience frequent care transitions, particularly from hospital to home, which are often poorly coordinated and fragmented. We conducted a pragmatic randomized controlled trial to test the implementation and effectiveness of Community Assets Supporting Transitions (CAST), an evidence-informed nurse-led intervention to support older adults with multimorbidity and depressive symptoms with the aim of improving health outcomes and enhancing transitions from hospital to home. This trial was conducted in three sites, representing suburban/rural and urban communities, within two health regions in Ontario, Canada.

Effectiveness of a nurse-led hospital-to-home transitional care intervention for older adults with multimorbidity and depressive symptoms: A pragmatic randomized controlled trial.

Objective: To evaluate the effectiveness of a nurse-led hospital-to-home transitional care intervention versus usual care on mental functioning (primary outcome), physical functioning, depressive symptoms, anxiety, perceived social support, patient experience, and health service use costs in older adults with multimorbidity (≥ 2 comorbidities) and depressive symptoms.

Design And Setting: Pragmatic multi-site randomized controlled trial conducted in three communities in Ontario, Canada. Participants were allocated into two groups of intervention and usual care (control).

Study protocol for a hospital-to-home transitional care intervention for older adults with multiple chronic conditions and depressive symptoms: a pragmatic effectiveness-implementation trial.

Background: Older adults (> 65 years) with multiple chronic conditions (MCC) and depressive symptoms experience frequent transitions between hospital and home. Care transitions for this population are often poorly coordinated and fragmented, resulting in increased readmission rates, adverse medical events, decreased patient satisfaction and safety, and increased caregiver burden. There is a dearth of evidence on best practices in the provision of transitional care for older adults with MCC and depressive symptoms transitioning from hospital-to-home.

Training and Maintaining System-Wide Reliability in Outcome Management.

The Child and Adolescent Functional Assessment Scale (CAFAS) is widely used for outcome management, for providing real time client and program level data, and the monitoring of evidence-based practices. Methods of reliability training and the assessment of rater drift are critical for service decision-making within organizations and systems of care. We assessed two approaches for CAFAS training: external technical assistance and internal technical assistance.