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Centre of Research Excellence in Optimising Care in the Home for Older Australians

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Research Stream 3

What are effective interventions to optimise care at home?

Research overview

Streams

Stream 1: Exploration

Stream 2: Preparation

Stream 3: Implementation

Stream 4: Sustainment

Seed funding

Stream 3 will focus on implementing and testing interventions for improving care transitions for older people. Points of transition across the pathway of care from home to hospital and back home are a time of vulnerability, with increased potential for decline and for care to be fragmented (due to issues including lack of information handover at discharge and increased care needs following a hospital stay), increasing the likelihood of re-presentation to hospital. Projects in this stream will address two critical points in this pathway to reduce unnecessary and preventable hospital presentations and re-admissions – identification of risk and deterioration pre-hospital, and discharge and transition home from hospital.

Project 3.1: Implementing the 'home check' digital health tool to prevent injuries and falls in older people and support ageing in place

Project leads: Professor Kate Laver and Professor Stacey George

Rationale: We know that older people want to stay in their own homes for as long as possible. With ageing and associated functional decline, as well as strong evidence showing that most falls occur within the home environment, it is critical to consider home adaptation to maintain access within the home and prevent falls. At present, older people with complex access or safety needs can be referred for an occupational therapy home environment assessment, but this usually only occurs after falls or injuries. Worse, there can be significant costs and waiting times due to workforce shortages. In previous work, Professor Kate Laver worked with older people to co-design a digital health tool – ‘Home Check’ – that aimed to educate and empower older people and their families to undertake their own home assessment and understand what home modifications could be made to support ageing in place. Preliminary testing showed that the tool is highly feasibly and there was strong agreement between self-assessment and occupational therapy assessment. 

Building on this work, we will conduct implementation research to embed access and use of the tool as part of routine primary care assessments (for people over 75 and Aboriginal people over 55). Uptake and efficacy of the tool will be assessed (i.e., did older people and their families take actions to improve home access and safety as recommended by the tool?).

Project 3.2: Rapid identification and response to deterioration in home care clients

Project leads: Professor Frances Batchelor

Rationale: Failure to respond to clinical deterioration and functional decline is associated with poor health outcomes, increased risk of hospital admission and increased morbidity and mortality. Early detection and intervention can assist in preventing minor issues from escalating. Preliminary work by Professor Frances Batchelor has highlighted the importance of involving frontline home care workers for older people in early recognition and response. Microlearning is a promising approach to upskilling frontline staff who are time poor and often working in isolation. 

We will build on this preliminary work and undertake an implementation pilot trial with aged care staff to assess feasibility, acceptability and knowledge/behaviour outcomes of a microlearning program on recognising and responding to deterioration in home care clients.

Project 3.3: Shared-care models when transitioning back home after a hospital transition

Project leads: Professor Gillian Harvey, Professor Maria Crotty, Professor Jonathon Karnon

Rationale: The fragmented information systems across acute, primary and aged care have made tracking of older people across a pathway of care extremely difficult, particularly when they have a hospital admission. This means older people who receive home care are often invisible in the health system, making it challenging to implement any post-hospital intervention to avoid preventable hospital readmission. A digital alert could effectively and efficiently identify home care recipients in hospital and inform a shared-care model – with the older person and family carers, the hospital system, general practitioners and aged care providers working together – to facilitate the older person’s discharge and transition of care to home.

Current work led by Profession Gillian Harvey and Professor Maria Crotty is testing a transitional care intervention for older people discharged from hospital to permanent residential aged care to reduce the likelihood of an unplanned hospital re-presentation. Following establishment of a digital platform to identify home care recipients in the hospital electronic medical record in Project 4.2, Project 3.3 will co-design and pilot a transitional shared-care model for older home care recipients discharged from hospital. The model will be pilot tested and the feasibility and acceptability of the co-designed intervention will be assessed. This will generate a future model of transitional shared-care with pilot data to inform a subsequent grant application for a fully powered effectiveness-implementation trial.