Why the study?
While strategies exist to integrate care and reduce preventable readmissions for older patients, implementing them at scale is challenging.
Do out-of-hospital care programs and quality improvement collaboratives reduce unplanned hospitalisations and emergency department encounters in older people?
Do out-of-hospital care programs and quality improvement collaboratives reduce unplanned hospitalisations and emergency department encounters in older people?
This study protocol outlines a multi-faceted approach using risk profiling, evaluation of out-of-hospital services, and a quality improvement collaborative to reduce avoidable hospitalisations in older people.
May inform scalable transitional care strategies for older adults; leaves open effectiveness in reducing readmissions.
BACKGROUND: Repeated admission to hospital can be stressful for older people and their families and puts additional pressure on the health care system. While there is some evidence about strategies to better integrate care, improve older patients' experiences at transitions of care, and reduce preventable hospital readmissions, implementing these strategies at scale is challenging. This program of research comprises multiple, complementary research activities with an overall goal of improving the care for older people after discharge from hospital. The program leverages existing large datasets and an established collaborative network of clinicians, consumers, academics, and aged care providers. METHODS: The program of research will take place in South Australia focusing on people aged 65 and over. Three inter-linked research activities will be the following: (1) analyse existing registry data to profile individuals at high risk of emergency department encounters and hospital admissions; (2) evaluate the cost-effectiveness of existing 'out-of-hospital' programs provided within the state; and (3) implement a state-wide quality improvement collaborative to tackle key interventions likely to improve older people's care at points of transitions. The research is underpinned by an integrated approach to knowledge translation, actively engaging a broad range of stakeholders to optimise the relevance and sustainability of the changes that are introduced. DISCUSSION: This project highlights the uniqueness and potential value of bringing together key stakeholders and using a multi-faceted approach (risk profiling; evaluation framework; implementation and evaluation) for improving health services. The program aims to develop a practical and scalable solution to a challenging health service problem for frail older people and service providers.
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Harvey et al. (2021) studied this question.
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