An integrated knowledge translation approach to address avoidable rehospitalisations and unplanned admissions for older people in South Australia: implementation and evaluation program plan

Gillian Harvey,Maria Crotty,Carmel Mcnamara,Alice Bourke,Maria C Inacio,Kate Laver,Jesmin Rupa,John Forward,Jonathan Karnon,Robert N Jorissen,John Maddison,Elizabeth A Lynch,Clarabelle T Pham,Craig Whitehead

doi:10.1186/s43058-021-00141-w

Abstract

BackgroundRepeated 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.MethodsThe 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.DiscussionThis 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.

Highlights

Repeated admission to hospital can be stressful for older people and their families and puts additional pressure on the health care system
This study protocol introduces a state-wide, multi-sectoral approach to tackling a complex problem that affects older people at high risk of repeated hospital admission
Few studies have examined the combination of individual, medication, system, and hospitalassociated factors that together could be associated with frequent hospital admissions

Summary

Introduction

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. A wide range of medical conditions and health care-related factors such as self-rated poor health status, frailty, frequent falls, comorbidity, polypharmacy, overuse and underuse of medications, depression, anxiety, heart failure, cognitive impairment, higher number of primary care visits, and admission to nursing home have been identified [5, 17,18,19,20,21,22]. Few studies have examined the combination of individual, medication, system, and hospitalassociated factors that together could be associated with frequent hospital admissions

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