A Multi-Method Study to Develop and Pilot Test an Interprofessional Transitional Care Model for Frail Older Adults - AdvantAGE.
Isabel Pfundstein, Oliver Mauthner, Cynthia O Gschwind and 4 others
PMID 40077946WHAT IT FOUND
An interprofessional transitional care model, with nurse-led home visits, was piloted in 62 frail older adults; 14 were readmitted.
It refined the model but did not test whether it reduces readmissions.
Key findings
01Advanced practice nurses led home visits for 62 participants, with the intervention lasting up to 90 days and averaging 69 days and 1 to 29 visits.
02Fourteen of the 62 participants were readmitted during the 10-month pilot, and root-cause analysis judged four readmissions avoidable and ten unavoidable.
03The pilot changed the model by adding a first home visit medication brown bag review, weekly visits for the first 4 weeks after discharge, and explicit timing for emergency contacts and follow-up.
STILL TO COME
How it was doneWhat they foundWhat it means for OTsWhat it means for RNs
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What it does not show
The pilot was descriptive and exploratory, aimed at feasibility and adaptation, so it did not test whether the model reduces rehospitalisation. The paper reports 14 readmissions among 62 participants in a descriptive exploratory pilot, so it cannot be interpreted as an effect of the intervention. Many eligible patients did not participate: 67 of 137 opted out, and 8 of 70 enrolled stopped before the first home visit, so the pilot may represent a selected group. The model was changed during the pilot, including eligibility, medication review, visit frequency and coordination timing, so the final model was not tested as delivered. The study was conducted in one Swiss geriatric hospital and local context, so it may not apply to other healthcare systems. The pilot lasted 10 months, so longer-term outcomes are not reported.
Declared interests
The authors declare no conflicts of interest. The study was a collaboration between the cantonal health department and a Swiss geriatric hospital, and the transitional care service was funded by the Canton of Basel-Stadt for 36 months.
The easy way to misread this
Do not conclude that this transitional care model reduces rehospitalisation. It was a descriptive exploratory pilot with 62 participants, aimed at feasibility and adaptation, so the readmission rate cannot be interpreted as an effect of the model.