Grant: Operating Grant: Transitions in Care - Best and Wise Practices Grants

When patients are unprepared to manage their care and recovery after discharge from hospital, they may not know the warning signs that indicate their health conditions are getting worse. A lack of preparation may lead to some patients waiting too long to get medical help, causing their health conditions to get worse. Other patients may visit the emergency room unnecessarily. For patients in rural communities, who usually do not live close to medical services, knowing the signs that their health conditions are getting worse and what to do about them is especially important. In our prior research, older rural patients and their families indicated that: 1) their most pressing unmet need is how to detect and respond to signs of worsening health conditions, and 2) a healthcare service called the warning signs intervention would help meet this need. The warning signs intervention was designed specifically to prepare patients to detect and respond to the warning signs of worsening health conditions. Patients who received the intervention had more knowledge and confidence in managing changes in their health conditions at home; they had fewer emergency room visits and hospital readmissions than patients who did not receive the intervention. However, how best to support healthcare providers in implementing the warning signs intervention in rural communities is not clear. In this project, we will invite healthcare providers to tell us what they think about the intervention and what they need to provide it in rural communities. The results will guide us in developing a plan to help healthcare providers give the intervention to older rural patients and their families. The plan is expected to improve healthcare providers' ability to give the intervention and older patients' and families' ability to manage warning signs at home after hospital discharge, while reducing emergency room visits, hospital readmissions, and the cost of care in Ontario's healthcare system.