The Problem

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.

The opportunity

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).

 

The Question

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?

 

Our Approach

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.
 

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Our Team

This trial is a multi-provincial collaboration led by home care partners, home care collaborators, researchers, and clinicians.

Team Lead:

Andrew P. Costa, PhD - McMaster University

Wave 1 Partners:

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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

Co-Investigators:         
          
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



 

Funding

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PARTNERS

Thanks to the Canadian Institute for Health Research, and trial partners HNHB LHIN, Vancouver Island Health Authority, and the Western Health Authority.