Systems Addressing Frail Elders (SAFE) Care Implementation

NCT ID: NCT02854826

Last Updated: 2018-08-31

Basic Information

• Recruitment Status: COMPLETED
• Total Enrollment: 330 participants
• Study Classification: OBSERVATIONAL
• Study Start Date: 2016-07-01
• Study Completion Date: 2018-07-27

Brief Summary

Systems Addressing Frail Elders (SAFE) Care is a nurse-led interprofessional team model to rapidly identify and provide safe and effective inpatient care to high risk older adults and help support their successful transition back to the community. Developed and demonstrated to be effective in one hospital - the model is now being disseminated and studied in three additional hospitals (multiple organizational case study).

Detailed Description

Three Magnet hospitals in Los Angeles County (Huntington Hospital, Torrance Memorial Medical Center and Ronald Reagan UCLA Health System) are collaborating on this demonstration and evaluation project (Multiple Case-Study Design). The project will engage interprofessional hospital leadership; provide training and coaching in implementation processes of the SAFE Care model; and track outcome of the SAFE Care model as implemented in the three collaborating site hospitals (three case studies). The investigators hope to contribute to the existing state of the science in dissemination and implementation of evidenced-based innovations. The collective data from the three sites (collected through interviews with hospital leadership and staff and with de-identified patient data on program implementation outcomes) will provide information about the effectiveness of the implementation process and support further dissemination.

Conditions

Frail Older Adutls

Study Design

• Observational Model Type: OTHER
• Study Time Perspective: PROSPECTIVE

Study Groups

UCLA Ronald Reagan Medical Center

Site 1 (UCLA Regan Medical Center): Leaders from nursing, pharmacy, social work/case management, physician, administration, performance improvement, information systems and the Nursing Research/Evidence Based Practice Council will implement, monitor and evaluate the SAFE Care model of care. Two nursing units will be identified for staff training in screening at-risk older adults. One units will be randomly selected to initiate the SAFE Care program. The "comparison" unit staff will screen for at-risk patients and continue usual high standard of care assessments and care planning. Both units will be closely followed with formative and summative evaluation data presented for local and all-site findings.

SAFE Care model of care

Intervention Type: OTHER

SAFE Care Model Site Intervention:

1. Endorse best practices for frail patients;

2. Identify frail patients promptly using multi-dimensional screening and assessments;

3. Employ interprofessional unit-based care team approach to frailty risk reduction during inpatient stay and create post-acute care transitions (PACT) plan recommendations;

4. Develop electronic health record templates for patient-centered interprofessional frailty notes;

5. Communicate PACT plans to primary care providers to promote safe transitions to the ambulatory setting and across the continuum of care.

6. Increase awareness, improve management of frailty, and improve overall health and well-being for adults who are frail or at risk of becoming frail.

Huntington Hospital

Site 2 (Huntington Hospital): Leaders from nursing, pharmacy, social work/case management, physician, administration, performance improvement, information systems and the Nursing Research Council/ Evidence Based Practice will implement, monitor and evaluate the SAFE Care model of care. Two nursing units will be identified for staff training in screening at-risk older adults. One units will be randomly selected to initiate the SAFE Care program. The "comparison" unit staff will screen for at-risk patients and continue usual high standard of care assessments and care planning. Both units will be closely followed with formative and summative evaluation data presented for local and all-site findings.

SAFE Care model of care

Intervention Type: OTHER

SAFE Care Model Site Intervention:

1. Endorse best practices for frail patients;

2. Identify frail patients promptly using multi-dimensional screening and assessments;

3. Employ interprofessional unit-based care team approach to frailty risk reduction during inpatient stay and create post-acute care transitions (PACT) plan recommendations;

4. Develop electronic health record templates for patient-centered interprofessional frailty notes;

5. Communicate PACT plans to primary care providers to promote safe transitions to the ambulatory setting and across the continuum of care.

6. Increase awareness, improve management of frailty, and improve overall health and well-being for adults who are frail or at risk of becoming frail.

Torrance Memorial Hospital

Site 3 (Torrance Memorial Hospital): Leaders from nursing, pharmacy, social work/case management, physician, administration, performance improvement, information systems and the Nursing Research/ Evidence Based Practice Council will implement, monitor and evaluate the SAFE Care model of care. Two nursing units will be identified for staff training in screening at-risk older adults. One units will be randomly selected to initiate the SAFE Care program. The "comparison" unit staff will screen for at-risk patients and continue usual high standard of care assessments and care planning. Both units will be closely followed with formative and summative evaluation data presented for local and all-site findings.

SAFE Care model of care

Intervention Type: OTHER

SAFE Care Model Site Intervention:

1. Endorse best practices for frail patients;

2. Identify frail patients promptly using multi-dimensional screening and assessments;

3. Employ interprofessional unit-based care team approach to frailty risk reduction during inpatient stay and create post-acute care transitions (PACT) plan recommendations;

4. Develop electronic health record templates for patient-centered interprofessional frailty notes;

5. Communicate PACT plans to primary care providers to promote safe transitions to the ambulatory setting and across the continuum of care.

6. Increase awareness, improve management of frailty, and improve overall health and well-being for adults who are frail or at risk of becoming frail.

Interventions

SAFE Care model of care

SAFE Care Model Site Intervention:

1. Endorse best practices for frail patients;

2. Identify frail patients promptly using multi-dimensional screening and assessments;

3. Employ interprofessional unit-based care team approach to frailty risk reduction during inpatient stay and create post-acute care transitions (PACT) plan recommendations;

4. Develop electronic health record templates for patient-centered interprofessional frailty notes;

5. Communicate PACT plans to primary care providers to promote safe transitions to the ambulatory setting and across the continuum of care.

6. Increase awareness, improve management of frailty, and improve overall health and well-being for adults who are frail or at risk of becoming frail.

Intervention Type: OTHER

Eligibility Criteria

Inclusion Criteria

Organizational Leadership Nursing Unit Leadership/staff Adults aged 65 years

Exclusion Criteria

65 years and older that are on hospice protocols or dying/comfort care protocols.

• Minimum Eligible Age: 18 Years
• Maximum Eligible Age: 110 Years
• Eligible Sex: ALL
• Accepts Healthy Volunteers: No

Sponsors

UniHealth Foundation

UNKNOWN

Sponsor Role: collaborator

Ronald Reagan Medical Center

UNKNOWN

Sponsor Role: collaborator

Huntington Hospital

OTHER_GOV

Sponsor Role: collaborator

Torrance Memorial

UNKNOWN

Sponsor Role: collaborator

Cedars-Sinai Medical Center

OTHER

Sponsor Role: lead

Responsible Party

Linda Burnes Bolton

DrPH, RN, FAAN, CNE, CNO, VP of Nursing

Responsibility Role: PRINCIPAL_INVESTIGATOR

Principal Investigators

Lianna Z Ansryan, MSN

Role: STUDY_DIRECTOR

Cedars Sinai

Other Identifiers

44067

Identifier Type: -

Identifier Source: org_study_id