Grant: Travel Awards - Institute Community Support

When older adults with multiple illnesses get discharged from a hospital stay, they have high chances of being readmitted to the hospital or visiting the Emergency Department in the months following their discharge. Many of these older adults are forced to return to hospital so soon because of medication errors, lack of ability to manage their conditions at home, and communication lapses between hospital staff and community caregivers. In the United States and New Zealand, Nurse Practitioner-led care transition programs have helped older adults transition home and stay out of hospital longer. These programs feature a pre-discharge visit while the patient is in hospital and post-discharge home visits, all by the same Nurse Practitioner. During these visits, the Nurse Practitioner checks patients' medications and guides them through a personalized care plan. This study is the first to look at whether a Nurse Practitioner-led care transition program can help older adults in Canada transition home more smoothly, thereby avoiding Emergency Department visits and readmissions. In addition to testing whether this type of hospital-to-home program reduces hospital readmissions, this study also identifies why certain components of the program did or did not meet their goals. This information on the processes that led to program successes and failures can be used to guide future hospital-to-home programs in Canada and abroad.