The development, implementation and evaluation of a transitional care programme to improve outcomes of frail older patients after hospitalisation

Noor Heim; Herbert Rolden; Esther M van Fenema; Annelies W E Weverling-Rijnsburger; Jolien P Tuijl; Peter Jue; Anna M Oleksik; Anton J M de Craen; Simon P Mooijaart; Gerard Jan Blauw; Rudi G J Westendorp; Roos C van der Mast; Irma E C van Everdinck

doi:10.1093/ageing/afw098

The development, implementation and evaluation of a transitional care programme to improve outcomes of frail older patients after hospitalisation

Noor Heim, Herbert Rolden, Esther M van Fenema, Annelies W E Weverling-Rijnsburger, Jolien P Tuijl, Peter Jue, Anna M Oleksik, Anton J M de Craen, Simon P Mooijaart, Gerard Jan Blauw, Rudi G J Westendorp, Roos C van der Mast, Irma E C van Everdinck

6 Citations (Scopus)

Abstract

BACKGROUND: fragmented healthcare systems are poorly suited to treat the increasing number of older patients with multimorbidity.

OBJECTIVE: to report on the development, implementation and evaluation of a regional transitional care programme, aimed at improving the recovery rate of frail hospitalised older patients.

METHODS: the programme was drafted in co-creation with organisations representing older adults, care providers and knowledge institutes. Conducting an action research project, the incidence of adverse outcomes within 3 months after hospital admission, and long-term care expenses (LTCE) were compared between samples in 2010-11 (pre-programme) and 2012-13 (post-programme) in frail and non-frail patients. Hospitalised patients aged ≥70 years were included in four hospitals in the targeted region.

RESULTS: developed innovations addressed (i) improved risk management; (ii) delivery of integrated, function-oriented care; (iii) specific geriatric interventions; and (iv) optimisation of transfers. The incidence of adverse outcomes was compared in 813 and 904 included patients respectively in the two samples. In frail patients, the incidence of adverse outcomes decreased from 49.2% (149/303) in the pre-programme sample to 35.5% (130/366) in the post-programme sample. The risk ratio (RR), adjusted for heterogeneity between hospitals, was 0.72 (95% CI: 0.60-0.87). In non-frail patients the incidence of adverse outcomes remained unchanged (RR: 1.02, 95% CI: 0.76-1.36). LTCE were similar in the two samples.

CONCLUSIONS: by involving stakeholders in designing and developing the transitional care programme, commitment of healthcare providers was secured. Feasible innovations in integrated transitional care for frail older patients after hospitalisation were sustainably implemented from within healthcare organisations.

Original language	English
Journal	Age and Ageing
Volume	45
Issue number	5
Pages (from-to)	642-651
Number of pages	10
ISSN	0002-0729
DOIs	https://doi.org/10.1093/ageing/afw098
Publication status	Published - 1 Sept 2016

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Heim, N., Rolden, H., van Fenema, E. M., Weverling-Rijnsburger, A. W. E., Tuijl, J. P., Jue, P., Oleksik, A. M., de Craen, A. J. M., Mooijaart, S. P., Blauw, G. J., Westendorp, R. G. J., van der Mast, R. C., & van Everdinck, I. E. C. (2016). The development, implementation and evaluation of a transitional care programme to improve outcomes of frail older patients after hospitalisation. Age and Ageing, 45(5), 642-651. https://doi.org/10.1093/ageing/afw098

Heim, N, Rolden, H, van Fenema, EM, Weverling-Rijnsburger, AWE, Tuijl, JP, Jue, P, Oleksik, AM, de Craen, AJM, Mooijaart, SP, Blauw, GJ, Westendorp, RGJ, van der Mast, RC & van Everdinck, IEC 2016, 'The development, implementation and evaluation of a transitional care programme to improve outcomes of frail older patients after hospitalisation', Age and Ageing, vol. 45, no. 5, pp. 642-651. https://doi.org/10.1093/ageing/afw098

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title = "The development, implementation and evaluation of a transitional care programme to improve outcomes of frail older patients after hospitalisation",

abstract = "BACKGROUND: fragmented healthcare systems are poorly suited to treat the increasing number of older patients with multimorbidity.OBJECTIVE: to report on the development, implementation and evaluation of a regional transitional care programme, aimed at improving the recovery rate of frail hospitalised older patients.METHODS: the programme was drafted in co-creation with organisations representing older adults, care providers and knowledge institutes. Conducting an action research project, the incidence of adverse outcomes within 3 months after hospital admission, and long-term care expenses (LTCE) were compared between samples in 2010-11 (pre-programme) and 2012-13 (post-programme) in frail and non-frail patients. Hospitalised patients aged ≥70 years were included in four hospitals in the targeted region.RESULTS: developed innovations addressed (i) improved risk management; (ii) delivery of integrated, function-oriented care; (iii) specific geriatric interventions; and (iv) optimisation of transfers. The incidence of adverse outcomes was compared in 813 and 904 included patients respectively in the two samples. In frail patients, the incidence of adverse outcomes decreased from 49.2% (149/303) in the pre-programme sample to 35.5% (130/366) in the post-programme sample. The risk ratio (RR), adjusted for heterogeneity between hospitals, was 0.72 (95% CI: 0.60-0.87). In non-frail patients the incidence of adverse outcomes remained unchanged (RR: 1.02, 95% CI: 0.76-1.36). LTCE were similar in the two samples.CONCLUSIONS: by involving stakeholders in designing and developing the transitional care programme, commitment of healthcare providers was secured. Feasible innovations in integrated transitional care for frail older patients after hospitalisation were sustainably implemented from within healthcare organisations.",

author = "Noor Heim and Herbert Rolden and {van Fenema}, {Esther M} and Weverling-Rijnsburger, {Annelies W E} and Tuijl, {Jolien P} and Peter Jue and Oleksik, {Anna M} and {de Craen}, {Anton J M} and Mooijaart, {Simon P} and Blauw, {Gerard Jan} and Westendorp, {Rudi G J} and {van der Mast}, {Roos C} and {van Everdinck}, {Irma E C}",

year = "2016",

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doi = "10.1093/ageing/afw098",

language = "English",

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TY - JOUR

T1 - The development, implementation and evaluation of a transitional care programme to improve outcomes of frail older patients after hospitalisation

AU - Heim, Noor

AU - Rolden, Herbert

AU - van Fenema, Esther M

AU - Weverling-Rijnsburger, Annelies W E

AU - Tuijl, Jolien P

AU - Jue, Peter

AU - Oleksik, Anna M

AU - de Craen, Anton J M

AU - Mooijaart, Simon P

AU - Blauw, Gerard Jan

AU - Westendorp, Rudi G J

AU - van der Mast, Roos C

AU - van Everdinck, Irma E C

PY - 2016/9/1

Y1 - 2016/9/1

N2 - BACKGROUND: fragmented healthcare systems are poorly suited to treat the increasing number of older patients with multimorbidity.OBJECTIVE: to report on the development, implementation and evaluation of a regional transitional care programme, aimed at improving the recovery rate of frail hospitalised older patients.METHODS: the programme was drafted in co-creation with organisations representing older adults, care providers and knowledge institutes. Conducting an action research project, the incidence of adverse outcomes within 3 months after hospital admission, and long-term care expenses (LTCE) were compared between samples in 2010-11 (pre-programme) and 2012-13 (post-programme) in frail and non-frail patients. Hospitalised patients aged ≥70 years were included in four hospitals in the targeted region.RESULTS: developed innovations addressed (i) improved risk management; (ii) delivery of integrated, function-oriented care; (iii) specific geriatric interventions; and (iv) optimisation of transfers. The incidence of adverse outcomes was compared in 813 and 904 included patients respectively in the two samples. In frail patients, the incidence of adverse outcomes decreased from 49.2% (149/303) in the pre-programme sample to 35.5% (130/366) in the post-programme sample. The risk ratio (RR), adjusted for heterogeneity between hospitals, was 0.72 (95% CI: 0.60-0.87). In non-frail patients the incidence of adverse outcomes remained unchanged (RR: 1.02, 95% CI: 0.76-1.36). LTCE were similar in the two samples.CONCLUSIONS: by involving stakeholders in designing and developing the transitional care programme, commitment of healthcare providers was secured. Feasible innovations in integrated transitional care for frail older patients after hospitalisation were sustainably implemented from within healthcare organisations.

AB - BACKGROUND: fragmented healthcare systems are poorly suited to treat the increasing number of older patients with multimorbidity.OBJECTIVE: to report on the development, implementation and evaluation of a regional transitional care programme, aimed at improving the recovery rate of frail hospitalised older patients.METHODS: the programme was drafted in co-creation with organisations representing older adults, care providers and knowledge institutes. Conducting an action research project, the incidence of adverse outcomes within 3 months after hospital admission, and long-term care expenses (LTCE) were compared between samples in 2010-11 (pre-programme) and 2012-13 (post-programme) in frail and non-frail patients. Hospitalised patients aged ≥70 years were included in four hospitals in the targeted region.RESULTS: developed innovations addressed (i) improved risk management; (ii) delivery of integrated, function-oriented care; (iii) specific geriatric interventions; and (iv) optimisation of transfers. The incidence of adverse outcomes was compared in 813 and 904 included patients respectively in the two samples. In frail patients, the incidence of adverse outcomes decreased from 49.2% (149/303) in the pre-programme sample to 35.5% (130/366) in the post-programme sample. The risk ratio (RR), adjusted for heterogeneity between hospitals, was 0.72 (95% CI: 0.60-0.87). In non-frail patients the incidence of adverse outcomes remained unchanged (RR: 1.02, 95% CI: 0.76-1.36). LTCE were similar in the two samples.CONCLUSIONS: by involving stakeholders in designing and developing the transitional care programme, commitment of healthcare providers was secured. Feasible innovations in integrated transitional care for frail older patients after hospitalisation were sustainably implemented from within healthcare organisations.

U2 - 10.1093/ageing/afw098

DO - 10.1093/ageing/afw098

M3 - Journal article

C2 - 27298381

SN - 0002-0729

VL - 45

SP - 642

EP - 651

JO - Age and Ageing

JF - Age and Ageing

IS - 5

ER -

The development, implementation and evaluation of a transitional care programme to improve outcomes of frail older patients after hospitalisation

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