Home care clients are a large and expanding subgroup of medically complex older adults with relatively poor access to effective chronic disease management. They have double the emergency department utilization rate compared to nursing home residents or other older populations. Effective chronic disease management in home care has been limited by insufficient targeting of clients with most need or most likely to benefit.
We developed and validated a prognostic case-finding tool for home care known as the Detection of Indicators and Vulnerabilities of Emergency Room Trips (DIVERT) Scale. From evidence-based guidelines developed – in part – by our team we developed a scalable chronic disease management model known are DIVERT-CARE (Collaboration, Action, Research, and Evaluation).
Can DIVERT-CARE - implemented by our partners - reduce cardio-respiratory symptoms, reduce unplanned emergency department visits, reduce unplanned hospital use, improve patient activation, or improve health-related quality of life for home care clients?
Most trials exclude frail older adults, so we have little evidence about the effectiveness of interventions used to support the health of older adults. In this trial, we are examining the ‘real-world’ effectiveness of an evidence-based case-finding tool and person-centered care model among frail home care clients.
We are conducting a pragmatic, cluster-randomized trial that leverages secondary de-identified patient records from our home care partners. The trial will include over 1080 clients from over 36 distinct geographic regions in Canada.
This trial is a multi-provincial collaboration led by home care partners, home care collaborators, researchers, and clinicians.
Andrew P. Costa, PhD - McMaster University
Wave 1 Partners:
Team Members (McMaster):
Connie Schumacher, RN, PhD
Aaron Jones, MSc
Darly Dash, MSc
Graham Campbell, MA
George Heckman, MD, M.Sc. | University of Waterloo
John Hirdes, PhD | University of Waterloo
Linda Lee, MD, MCISc(FM), CCFP, FCFP | McMaster University
Robert McKelvie, MSc, MD, PhD, FRCPC | McMaster University
Lori Mitchell | Winnipeg Regional Health Authority
Samir Sinha, MD, DPhil, FRCPC | Mount Sinai Hospital
Gina Agarwal, MD | McMaster University
Chaim Bell, PhD, MD, FRCPC | Mount Sinai Hospital
Veronique Boscart, RN, PhD | Conestoga College
Susan Bronskill, MSc, PhD | Institute for Clinical Evaluative Sciences
David Feeny | McMaster University
Paul Hebert, MHSc,MD, FRCPC | Centre Hospitalier de l'Universite de Montreal
Thanks to the Canadian Institute for Health Research, and trial partners HNHB LHIN, Vancouver Island Health Authority, and the Western Health Authority.