Evaluation of the STEP Intervention for Long-Term Care Residents Facing Hospital Transfer Decisions

NCT ID: NCT07153341

Last Updated: 2025-10-01

Basic Information

• Recruitment Status: RECRUITING
• Clinical Phase: NA
• Total Enrollment: 300 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2025-10-01
• Study Completion Date: 2027-09-01

Brief Summary

This trial will evaluate whether the Supporting Transitions and Empowering Preferences (STEP) toolkit can improve decision-making about hospital transfers in long-term care residents and their substitute decision-makers and enhance decision self-efficacy in nursing staff.

The trial will answer the questions:

• Does the STEP tool improve preparation for decision-making during acute health crises?
• Does it reduce decisional conflict and regret in residents and care partners following these crises?
• Does it improve nurse self-efficacy and documentation quality related to hospital transfer decisions?

Participants will:

• Use the STEP tool during key moments of care planning (admission, care conferences, and acute events)
• Complete short surveys measuring their preparedness, decisional conflict, and regret
• Be supported by trained nurses who use STEP to guide hospital transfer discussions

Researchers will compare data collected before and after the STEP tool is implemented at two long-term care homes to see if it improves shared decision-making and documentation related to hospital transfers.

Detailed Description

Background and Rationale: Transitions from long-term care (LTC) to hospital are complex and can offer both benefits and challenges to residents and care partners. While LTC-to-hospital transitions can improve health outcomes, particularly during acute deterioration, evidence also indicates that these transitions may disrupt continuity of care, increase stress, and misalign resident needs with hospital protocols. Nearly fifty percent of LTC residents in Canada experience hospital transitions annually, with approximately forty percent considered avoidable. Risks include non-evidence-based care, safety concerns, unnecessary interventions, and increased mortality rates. Transition decisions are influenced by residents' health status, medico-legal concerns, staff workload, and care partners' confidence in LTC care. These decisions are often reactive and shaped by unequal power dynamics rather than proactive, collaborative planning.

Given these challenges, and limitations in current monitoring systems such as the Minimum Data Set assessments, there is a critical need for a decision aid that supports informed, resident-centered planning. The Supporting Transitions and Empowering Preferences (STEP) tool was developed through interviews, co-design sessions, document analysis, and stakeholder engagement.

Objectives Primary Objective: Evaluate the impact of STEP on preparation for decision-making among residents and care partners following acute health crises.

Secondary Objectives: Assess the impact of STEP on decisional conflict and decisional regret among residents and care partners.

Tertiary Objectives: Examine the effect of STEP on nurses' self-efficacy as decision coaches and the quality of documentation regarding transition decisions.

Trial Design and Study Setting: A pre-post evaluation will be conducted at two LTC sites (Perley Health and Bruyère Health Saint-Louis LTC) to assess STEP's ability to prepare and support resident-care partner dyads in making hospital transition decisions. STEP will be implemented simultaneously at both sites.

Study Overview: Data will be collected for three months pre-intervention or until the target sample size is reached, followed by the intervention period. Nurses, nurse practitioners, social service workers, and physicians will receive STEP training, with designated champions supporting implementation. Data will be collected at three points: after intake meetings, after care conferences, and after acute events in which a transfer is considered.

Vanguard Phase Implementation: An initial vanguard phase involving approximately ten residents over four to six weeks will test feasibility, refine recruitment, and assess staff comfort before broader rollout.

Description of the Intervention (Overview): The STEP intervention includes two resources: an educational booklet about transition decisions and a structured decision aid. Staff will be trained on both in-person and telephone use, with sessions scheduled to accommodate different shifts. STEP will be introduced at admission, reviewed at post-admission or annual care conferences, and used during acute health events to guide structured conversations about hospital transfer decisions.

Monitoring Fidelity: Implementation fidelity will be monitored through nurse logs, informal discussions, and champion reports, assessing feasibility, acceptability, and adherence.

Data Collection Procedures (Overview): Dyads will be identified through care reports and hospital transfer notifications, with eligibility verified prior to consent. Data will be collected using secure REDCap software. For nurses, care conference and physician call notes will be reviewed to identify eligible cases. Surveys and brief interviews will assess experiences, confidence, and barriers to STEP use.

Analysis: Analyses will follow an intention-to-treat approach using Generalized Estimating Equations for repeated measures. Differences between groups will be examined using t-tests or chi-squared tests. Missing data will be minimized through follow-up; cases lost after three unsuccessful contact attempts will be excluded from analysis.

Conditions

LTC-to-hospital Transfer Decision-making

Study Design

• Allocation Method: NA
• Intervention Model: SINGLE_GROUP
• Primary Study Purpose: HEALTH_SERVICES_RESEARCH
• Blinding Strategy: NONE

Study Groups

STEP Intervention

Participants (resident-care partner dyads) in this arm will receive the STEP intervention. STEP is a decision aid designed to support shared decision-making about whether to transfer to hospital or remain in LTC during acute health events. It includes a brochure and structured decision-making guide used at three points in the resident's care journey: (1) upon LTC admission, (2) during annual care conferences, and (3) at the time of an acute medical event. LTC nurses will receive training to deliver the STEP tool and support residents and care partners in making informed, values-based transition decisions.

Group Type: EXPERIMENTAL

STEP Decision Support Toolkit

Intervention Type: BEHAVIORAL

The STEP toolkit includes (1) an educational booklet provided upon admission and annually, (2) condition-specific decision aids addressing common clinical scenarios, and (3) structured phone scripts for staff. STEP empowers residents and care partners to actively engage in decision-making, promotes care aligned with personal values, and supports staff in facilitating advance care planning to reduce unnecessary or complex transitions.

Interventions

STEP Decision Support Toolkit

The STEP toolkit includes (1) an educational booklet provided upon admission and annually, (2) condition-specific decision aids addressing common clinical scenarios, and (3) structured phone scripts for staff. STEP empowers residents and care partners to actively engage in decision-making, promotes care aligned with personal values, and supports staff in facilitating advance care planning to reduce unnecessary or complex transitions.

Intervention Type: BEHAVIORAL

Eligibility Criteria

Inclusion Criteria

Residents-care partner dyads:

• Must be residents of either Perley Health or Bruyère Health Saint-Louis LTC home.
• Residents must be 55 years of age or older.
• Must be able to communicate in French or English.

Both members of the dyad will be included where applicable. For dyads in which residents do not have the capacity to participate, inclusion will occur through the involvement of their substitute decision-maker (e.g., power of attorney for personal care).

LTC staff:

• Must be a nurse, nurse practitioner, social service worker or physician actively involved in care planning, annual conferences, or managing acute health events at Perley Health or Bruyère Health.
• Must have been employed at the LTC home for at least 6 months to ensure familiarity with the care environment and residents.
• Must play a role in facilitating discussions, providing clinical input (where applicable), or guiding decision-making processes related to hospital transitions or acute care management.
• Must be able to communicate in French or English.

• Minimum Eligible Age: 55 Years
• Eligible Sex: ALL
• Accepts Healthy Volunteers: No

Sponsors

Bruyère Health Research Institute.

OTHER

Sponsor Role: lead

Responsible Party

Responsibility Role: SPONSOR

Locations

Bruyère Health Saint-Louis Long-Term Care

Ottawa, Ontario, Canada

Site Status: RECRUITING

Perley Health

Ottawa, Ontario, Canada

Site Status: RECRUITING

Countries

Canada

Central Contacts

Daniel Kobewka, MD

Role: CONTACT

DKobewka@toh.ca

613-798-5555 ext. 13056

Alixe Ménard, MSc, PhD(c)

Role: CONTACT

alimenard@ohri.ca

613-798-5555 ext. 78777

References

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Reference Type: BACKGROUND

PMID: 27665753 (View on PubMed)

Marincowitz C, Preston L, Cantrell A, Tonkins M, Sabir L, Mason S. What influences decisions to transfer older care-home residents to the emergency department? A synthesis of qualitative reviews. Age Ageing. 2022 Nov 2;51(11):afac257. doi: 10.1093/ageing/afac257.

Reference Type: BACKGROUND

PMID: 36413591 (View on PubMed)

Gruneir A, Bronskill SE, Newman A, Bell CM, Gozdyra P, Anderson GM, Rochon PA. Variation in Emergency Department Transfer Rates from Nursing Homes in Ontario, Canada. Healthc Policy. 2016 Nov;12(2):76-88.

Reference Type: BACKGROUND

PMID: 28032826 (View on PubMed)

Gruneir A, Anderson GM, Rochon PA, Bronskill S. Transitions in long-term care and potential implications for quality reporting in Ontario, Canada. J Am Med Dir Assoc. 2010 Nov;11(9):629-35. doi: 10.1016/j.jamda.2010.07.007.

Reference Type: BACKGROUND

PMID: 21029997 (View on PubMed)

Cummings GG, McLane P, Reid RC, Tate K, Cooper SL, Rowe BH, Estabrooks CA, Cummings GE, Abel SL, Lee JS, Robinson CA, Wagg A. Fractured Care: A Window Into Emergency Transitions in Care for LTC Residents With Complex Health Needs. J Aging Health. 2020 Mar;32(3-4):119-133. doi: 10.1177/0898264318808908. Epub 2018 Nov 15.

Reference Type: BACKGROUND

PMID: 30442040 (View on PubMed)

Abraham S, Menec V. Transitions Between Care Settings at the End of Life Among Older Homecare Recipients: A Population-Based Study. Gerontol Geriatr Med. 2016 Dec 15;2:2333721416684400. doi: 10.1177/2333721416684400. eCollection 2016 Jan-Dec.

Reference Type: BACKGROUND

PMID: 28680944 (View on PubMed)

Menard A, Singh Y, Adams M, Bai JQA, Kobewka D, MacLeod KK. "We Didn't Ask to Be Sick:" Equipping Residents and Care Partners for Transitions From Long-Term Care to Hospital. J Am Geriatr Soc. 2025 Aug;73(8):2410-2421. doi: 10.1111/jgs.19535. Epub 2025 May 30.

Reference Type: BACKGROUND

PMID: 40444661 (View on PubMed)

Menard A, Konikoff L, Adams M, Singh Y, Scott MM, Yin CY, Kimura M, Kobewka D, Fung C, Isenberg SR, Kaasalainen S, Kierulf J, Molnar F, Shamon S, Wilson K, Kehoe MacLeod K; Ottawa Hospital Research Institute and Bruyere Health Research Institute. Supporting resident-centred decision-making about transitions from long-term care homes to hospital: a qualitative study protocol. BMJ Open. 2024 Nov 29;14(11):e086748. doi: 10.1136/bmjopen-2024-086748.

Reference Type: BACKGROUND

PMID: 39615892 (View on PubMed)

Other Identifiers

478736

Identifier Type: OTHER_GRANT

Identifier Source: secondary_id

M16-25-017

Identifier Type: -

Identifier Source: org_study_id