PRP121: Mapping care transition theories, models & frameworks for the development of a digital health tool: A rapid review protocol

Hardeep Singh, PhD, MScOT; Susan Law, PhD; Alana Armas, MSc; Carlotta Micaela Jarach, MSc; Carolyn Steele Gray, PhD, MA; Donna Plett; Jason Nie, MSc; Jasvinei Sritharan; Moriah Ellen, PhD, MBA; Rachel Thombs, BSN, RN; Terence Tang, MD, FRCPC; Michelle Nelson, PhD, MA


Context: Transitions from hospital to the primary care require coordinated efforts across the continuum of care. For older adults, these transitions are highly vulnerable periods, marked with high rates of re-hospitalization and avoidable adverse events. Digital health solutions have the potential to improve care transitions, but their use in clinical practice remains limited. Given the potential of digital health solutions to support older adults as they return home from the hospital and improve care coordination between hospital and primary care providers, it is pertinent to understand how to better integrate these solutions into care transitions in practice. Objective: To: i) synthesize theories, models and frameworks that inform the transition of care from hospital to home, ii) synthesize evidence relating to digital health that support transitions of care, iii) identify the extent to which the digital health aligns with theories, models and frameworks that inform hospital to home transitions, and iv) create recommendations that will inform the design of the Digital Bridge to Home intervention. Study Design and Analysis: A two-phased rapid review. Phase 1 will identify theories, models and frameworks that inform hospital to home transitions of care, and the results will be analyzed using a conceptual narrative synthesis. Phase 2 will identify digital health solutions that support hospital to home transitions of care. The results of Phase 1 and Phase 2 will be integrated using a narrative synthesis. Setting: Transitions of care from hospital to primary care. Population studied: Patients aged ≥60 years. Intervention: N/A. Outcome Measures: Studies included in phase 2 may examine rate of hospital re-admission, quality of life, quality of transitions, patient experiences with transitions, provider communication and teamwork and/or economic evaluations. Results: It is anticipated that this review will yield a comprehensive synthesis of literature on the theories, models and frameworks that inform the transition of care from hospital to primary care and identify enabling digital health solutions. Expected Outcomes: Study results will inform the design and implementation of a technology enabled care transition intervention research study (Digital Bridge) intended to support person-centered care transitions for older adults with complex care needs.

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