Programme de chercheur-intégré sur 4 ans

RÉSUMÉ

Background: Patients discharged from hospital currently experience fragmented care, repeated and lengthy emergency department (ED) visits, relapse into their earlier condition, and rapid cognitive and functional decline. These lead to patient and caregiver distress and to rising costs (1-17). The Acute Care for Elders (ACE) Program at Mount Sinai Hospital has developed strategies that improved the care transition experiences of the frail elderly from hospitals to the community, prevented hospital and ED readmissions, and reduced costs (13). Thousands of acute care organizations around the world could benefit from such programs if they were adapted to local contexts (18-22). WikiTrauma (a free online database containing knowledge tools in all areas of healthcare) and Wiki101 (an accompanying training course) can engage multiple stakeholders (including patients) to adapt such programs to their own contexts (23-28). Now our local managers and clinicians want to expand this “Wiki-suite” to other areas, including geriatrics.

Goal: To transform the health outcomes and quality of life for frail Canadian seniors who are discharged from hospital by using the Wiki-suite to adapting the ACE strategies for transition of care for the elderly to four hospital sites within the Centre intégré de santé et services sociaux de Chaudière-Appalaches (CISSS CA). Lessons learned will be used to scale up this process to further contexts within the CISSS CA and elsewhere.

Objectives: 1) adapt the ACE program, specifically its care transition component, to the CISSS CA, using the Wiki-suite; 2) implement the new ACE program and measure its impact and that of its new context-adapted wiki-based knowledge tools on clinician uptake of the program, patient autonomy, health outcomes, and healthcare resource utilization in Chaudière-Appalaches; 3) identify underlying mechanisms by which the Wiki-suite contributes to context-adaptation and to local uptake of adapted knowledge tools; 4) scale up the Wiki-suite by engaging policy makers and industry leaders to develop interoperability standards allowing integration of WikiTrauma content within local, provincial and national electronic medical record solutions across Canada.

Methods: Obj 1: Rapid, iterative user-driven design prototyping to adapt the ACE program to the CISSS CA context. Obj 2: Staggered implementation of the program across the 4 CISSS CA sites; interrupted time series to measure the impact of the new program and its context-adapted tools on patient autonomy and health outcomes, clinical uptake of the program, and healthcare resource utilization (e.g. readmission rates). Obj. 3: Parallel mixed-methods process evaluation study to understand the mechanisms by which the Wiki-suite contributes to adaptation and uptake of geriatric knowledge tools. Obj. 4: Meetings with local, provincial and national policymakers and industry leaders will be held to develop interoperability standards for integration of WikiTrauma content into electronic medical record solutions across Canada.

Expected results: 1) Context-adapted geriatric knowledge tools and improved transition care for the elderly in four hospitals in Quebec. 2) Evidence about effective strategies for adapting geriatric knowledge to local contexts. 3) An understanding of behavioral and cultural mechanisms by which the Wiki-suite enables innovation and open collaboration among patients, clinicians, decision makers and industry leaders. 4) Interoperability standards that will facilitate scaling up of effective, evidence-based context-adapted knowledge tools within local, provincial and national electronic medical record solutions.

DESCRIPTION DES PHASES DU PROJET

THE PROBLEM

People aged 65 and over represent 16% of the Canadian population, but also account for 42% of all acute care hospitalizations, i.e. 58% of all hospital days in our country (13). Seniors also represent a third of all patients consulting Emergency Departments (EDs) in Canada (29-30) and one in five are readmitted to hospital after discharge (31). These statistics place Canada as one of the worst among industrialized countries (29). This problem is expected to worsen as the country’s older population doubles in size over the coming two decades, with numbers of people 85 and older expected to quadruple (32). Seniors visit EDs because of inter-related chronic diseases or acute health and social issues (33), but these visits can have catastrophic consequences. Discharge adverse events result in unplanned readmissions (34-35), which occur after 10–30% of medical admissions (1-12,36-38), loss of physical, functional and/or cognitive capacity (39-43), or relapse. Added to poor health outcomes are patient and staff distress and dissatisfaction (1,44-45), and lawsuits concerning inadequate discharge planning are increasing (46). Although all Canadians benefit from a publicly funded universal healthcare system, healthcare delivery in Canada is the responsibility of a myriad of quasi-independent institutions and individuals. Health provider and information continuity is poor (47-48). Information from earlier visits are available to physicians only 22% of the time (49). Because they are the only common thread weaving through the healthcare continuum, older patients and their caregivers are obliged to manage their own care pathway. But they do not know how to navigate a vertically and horizontally fragmented system and are ill-equipped to assert themselves when their needs are not being properly met (1).

Some best-practice guidelines address these problems, such as Acute Care for Elders (ACE) (50-58). Unfortunately, these guidelines have only been implemented in a few dozen of the thousands of acute care organizations around the world (60). A major barrier to the implementation of best-practice guidelines is that these guidelines and tools cannot be easily transferred into different cultural, organizational and technical contexts. Knowledge producers (researchers) and knowledge users (patients, clinicians and decision makers), lack effective interventions to adapt knowledge to the local context, a crucial step in the knowledge-to-action framework (KTA) (61). Potential knowledge users may lack the skills, resources, or institutional culture necessary to apply knowledge locally and support their local institutions to learn new ways of operating. Experts have challenged researchers to find innovative solutions that support the involvement of local knowledge users in adapting knowledge tools to their contexts (19-22,62). Although local adaptation is a key step of the KTA framework, little is known about how to accomplish this step effectively (61,63-74).

OVERALL PROGRAM GOALS

Our immediate program goal is to improve transition care for the frail elderly in Canada. More specifically, our goal is to adapt an evidence-based and effective strategy, the ACE guidelines, specifically the Transitions and Community Care component, to the local context of the four hospital sites of the Centre intégré de santé et de services sociaux de Chaudière-Appalaches (CISSS CA) (61).

We plan to use two new knowledge translation (KT) interventions, WikiTrauma and Wiki101 (“the Wiki-suite”) to engage knowledge users (KU) in adapting the ACE transitions guidelines, to our local context. Our Wiki-suite is currently being implemented by the CISSS CA and will serve as its institutional memory to manage the implementation of best practices across all areas of care including to support the implementation of the ACE Program. WikiTrauma (https://sites.google.com/site/wikitraumaca/) is a wiki that contains free online knowledge tools in all fields of healthcare and Wiki101 is an online training course on how to use WikiTrauma. Even though our Wiki-suite was initially developed to implement best practices in trauma care (75), decision makers and clinicians decided to extend its use because of its usefulness in supporting the implementation of knowledge tools in all areas of care. Our ultimate goal is to learn from this experience to produce a new knowledge platform that can be used to adapt any healthcare improvement strategy to any local context, and to develop interoperability standards for nationwide adoption of these tools.

OBJECTIVES

• 1. Adapt the ACE program, specifically its care transition component, to the CISSS CA, using the Wiki-suite;

  2. Implement the new ACE program and measure its impact and that of its new context-adapted wiki-based knowledge tools on clinician uptake of the program, patient autonomy, health outcomes, and healthcare resource utilization in Chaudière-Appalaches;

  3. Identify underlying mechanisms by which the Wiki-suite contributes to context-adaptation and to local uptake of adapted knowledge tools;

  4. Scale up the Wiki-suite by engaging policy makers and industry leaders to develop interoperability standards allowing integration of WikiTrauma content within local, provincial and national electronic medical record solutions across Canada.

THEORETICAL RATIONALE

Objective 1: Since this research program concerns the use of a wiki as a KT intervention, we situate our proposed intervention in the Knowledge to Action (KTA) (76) framework (see Figure 1 in additional file). The Canadian Institutes of Health Research (CIHR) conceptualizes the KTA framework as “the relationship between knowledge creation and action, with each concept comprised of ideal phases or categories ... The action part of the process can be thought of as a cycle leading to implementation or application of knowledge … [it] represents the activities that may be needed for knowledge application” (77). One of the steps in the framework is adapting knowledge tools to local contexts. This is necessary because it: 1) reduces duplication of effort and optimizes use of existing resources; 2) encourages consideration of implementation and “fit”; 3) enhances applicability; and 4) engages local knowledge users, thus increasing uptake (78). The role of our wiki is to engage knowledge users in adapting knowledge tools to local contexts.

Objective 2: Adapting knowledge tools to the local context requires engaging stakeholders who know the local culture (e.g. language, religion, legal context), organizational structure and available resources (e.g. human, technical and financial). The Ottawa Model for Research Use (OMRU) (see Figure 2 in additional file) (79) is a useful framework for supporting knowledge users in considering the multiple factors involved when implementing evidence-based innovations. This will ensure that knowledge users: 1) use a rigorous process; 2) use an explicit participatory process involving relevant stakeholders; and 3) preserve the integrity of the evidence-based recommendations. Having used this model successfully for the implementation of a knowledge tool in the ED (80), I will use it again at all stages of this program, from adapting knowledge tools, evaluating their impact, exploring the mechanisms that influence that impact, to scaling up the intervention to further contexts.

Objectives 3 and 4: In addition to adapting successful interventions to local contexts, the KTA cycle also requires “scaling up” of effective interventions, i.e. their impact should not be restricted to a few local contexts but must be expanded so as to benefit more people and foster large-scale policy and program development on a lasting basis. In order to scale up these interventions, we need first to understand how the Wiki-suite, as an effective implementation strategy, can be adapted to multiple local contexts, i.e. the processes or factors that determine their impact on the studied outcomes. As part of our trial, I will therefore use the Theory of Planned Behavior (TPB) (see Figure 3 in additional file, 81) to identify the underlying behavioural mechanisms by which WikiTrauma and Wiki101 increase healthcare professionals’ adaptation of knowledge tools and leads to their increased use across the multiple sites of the CISSS CA. The TPB is well known for its application to the study of healthcare professionals’ behaviors (81-88). I have previously used this theory to understand trauma professionals’ intention to use a wiki to implement best practices (25,89). Once more is known about the way wikis work, scaling up will be possible, and relevant provincial, national and international stakeholders will be involved in integrating these new technologies into other ehealth applications across Quebec, Canada and abroad.

STATE OF THE KNOWLEDGE

The Mount Sinai ACE Program and its impact on transitions in care: Over the last six years, Mount Sinai Hospital has become Canada’s most widely recognized elder-friendly hospital. Located in Toronto, Ontario, Mount Sinai developed an Acute Care for Elders (ACE) program, implementing evidence-informed models and point-of-care interventions to improve patient, provider and system outcomes for frail elderly people. It demonstrated significant reductions in lengths of stay, admissions, readmissions and inappropriate resource utilization. It adopted an interprofessional team-based approach to care, integrating the expertise of geriatricians and geriatric psychiatrists, advanced practice nurses, social workers, therapists, pharmacists, dieticians and volunteers. Comparing the baseline performance year 2009 to 2014, Mount Sinai reduced total lengths of stay (12 days to 8 days), reduced alternate level of care days (20% reduction), reduced readmissions within 30 days (15% to 13%), improved rate of returning patients home as opposed to other institutional settings (71% to 79%), and increased rates of patient satisfaction (95% to 97%). These improvements, achieved despite admission rates of over-65s climbing by 37%, resulted in closure of eight medical beds and an estimated $6.7 million in acute care savings in 2014 (90).

The ACE strategy in four Quebec hospitals: In the CISSS CA there is a daily average of eight alternate-level patients (patients in acute care beds who are waiting to be discharged to a more appropriate setting), which far exceeds the Quebec Ministry of Health’s target. Furthermore, our 30-day readmission rate after discharge is 11.2% for patients aged over 65 years, indicating that we need to improve our elder care transitions. The problem facing the CISSS CA is common and rising across Canada. The so-called ACE Collaborative aims to scale up the Mount Sinai initiative and build the capacity of hospital leaders, front-line managers and providers to address the needs of acutely ill elderly. The ACE Program contains 18 components in 1) ED, 2) inpatient care; and 3) transitional and community-based care. In line with its own priority to improve elderly care and that of CIHR’s embedded clinician-scientist priority, the CISSS CA chose to implement the ACE transitional and community-based care component (Care Transition Interventions, or CTI) (13).

Care Transition Interventions: Quality of care during transitions can be improved by pre-discharge interventions, post-discharge interventions and interventions that cross the transition (1,44-45,50,91-94). The Care Transitions Measure (CTM) is a validated and widely-used measure of care transition quality (1,95). Interventions that bridge the transition include those that improve provider and information continuity (96-97). The ACE CTI Program improves transitions in care by providing structured discharge summaries, conducting follow-up telephone calls and providing a “transitions coach”. A transitions coach helps patients learn self-management skills beginning at discharge (50) and is usually a specially trained nurse. The coach helps patients learn to manage multiple prescriptions, follow post-hospital recommendations, and reconciles pre- and post-hospitalization medication lists. The coach uses a series of knowledge tools to empower patients and their caregivers, including patient decision aids (98), patient self-care guides and action plans (99-101). Other knowledge tools such as discharge checklists (102), discharge order sets and interprofessional care pathways (103-104) could also support transitions coaches. Coaches meet with each patient in hospital and then again at home. He/she teaches each patient how to communicate his or her needs more effectively, to identify a list of “red flags” that warrant an intervention, and ensures the patient's needs are met. The coach typically also phones three times in the month following discharge.

Using wikis to adapt CTI components to the Quebec context: The knowledge tools used with ACE CTI need to be be adapted to the CISSS CA. Wikis, or collaborative writing applications (105-106) are a category of social media whose popularity has surged in recent years (105,107-110). Although no two applications are identical, all consist of software that allow users to create online content that anyone can edit or supplement (111). We submit that using a collaborative wiki platform is an effective strategy for adapting knowledge tools to local contexts, as wikis were designed precisely to involve users interactively in the generation and application of knowledge (23). Wikis have been shown to increase professionals’ self-efficacy as regards their use of knowledge tools (108-109,112-113). In other words, the open and interactive nature of wikis empowers healthcare professionals to get involved in adapting knowledge tools to their local contexts (23-24,114 and see Figure 1 in additional file) (76) thus increasing the likelihood that they will use them.

Restricted-access wikis can also be used as knowledge management systems in highly security-sensitive fields. The US Government uses Intellipedia to support knowledge sharing among its CIA agents (115). The Canadian CPOE Toolkit created by the North York General Hospital (Ontario, Canada) stores and shares order sets across numerous hospitals in Ontario (116-118). Access and editing rights are restricted to certain individuals based on the needs of each community or organization that manages it. This restricted-access model is the one we are using for WikiTrauma to adapt trauma guidelines to the Quebec context (75). WikiTrauma now contains close to 2000 different knowledge tools (e.g. care protocols, order sets, patient decision aids) from five hospitals (see below) in multiple areas of care.

Knowledge preparation for the LEARNING WISDOM program: In preparation for the current proposal, I spent the last four years of my FRQS-funded program exploring wikis role in KT and producing the following outputs: a) a mixed-methods study using the TPB to identify the salient beliefs that need to be targeted in the implementation of a wiki (25); b) TPB-based questionnaires, using the beliefs identified, to survey 157 physicians and 292 allied health professionals in 12 Quebec trauma centres (89); c) a survey showing high intention among health professionals to use wiki-based knowledge tools (24-25) (see Table 1, Item 6 in additional file) (24); d) a scoping review on the use of wikis and collaborative writing applications in healthcare which identified 48 barriers (e.g., usability, reliability of information and workflow integration) and 91 facilitators (e.g., open-access, interoperability and mobile access) (23) and informed the planning of an ongoing Cochrane review (119); e) a CIHR-funded planning meeting involving 40 stakeholders to plan the implementation strategy and evaluation of WikiTrauma (see Table 2 in additional file, and https://goo.gl/e7nH8r); f) a CMPA-funded WikiTrauma pilot project to perform rapid prototyping and implementation of WikiTrauma and Wiki101 in five hospitals in Quebec (75) (see Figure 4 in Additional file); g) Wiki101 development and implementation: Wiki101 includes rewards (CME credits), role-play, social support (team assignments), persuasive communication, and feedback and monitoring after the course (see Figure 5 in Additional file); h) Context-adaptation of a decision aid: rapid prototyping and development of a decision aid to support shared and value-based decision making in a CISSS CA Intensive Care Unit (26). The resulting decision aid (www.wikidecision.org) was built in 6 months.

A wiki platform to support the Quebec integrated health reform: In 2015, Quebec’s Bill 10 forced a wave of mergers and created new integrated health and social services centres (CISSS) and integrated university health and social services centres (CIUSSS). Although the structural measures for integration are in place, other dimensions of integration, including continuity of care (knowledge management) and the establishment of common best practices remains a challenge. WikiTrauma is designed to support the integration of these areas by providing an open and easy to access communication tool. Using WikiTrauma to implement the ACE CTI components will facilitate vertical and horizontal integration of care by connecting the primary to the tertiary levels of care, and connecting services at the same level (e.g. public health, community health and home care). LEARNING WISDOM will thus provide a model for interprofessional collaboration, continuity of care, adaptation of best practices to the local context, and effective knowledge management (75).

RESEARCH PROGRAM

PHASE I (Objectives 1 and 2): The 12-month ACE Wiki Project : Using the Wiki-suite to create context-adapted CTI knowledge tools for the CISSS CA

Timeline: 2016-2017 (See Figure 6 and Table 3 in additional file)

Principal investigator: P. Archambault

Principal Knowledge User: Daniel Paré

Co-investigators and other knowledge users: See Table 4 in additional file.

Introduction: Phase I is funded within the CFHI/TVN/Mount Sinai ACE Collaborative Program. Our organization was selected among 15 Canadian hospitals and 3 international hospitals to implement a component of the Program. The component we will implement is the ACE CTI Program, which includes a series of pre-discharge, post-discharge and across transitions period interventions: 1) discharge summaries, 2) a transitions coach, and 3) systematic phone follow-up of frail elderly patients discharged from hospital and ED. The CISSS CA will also include broader use of its telemonitoring service (see health system partner document) currently only offered to patients of the community-based CLSC. With this project the CISSS CA will extend its use to all frail elderly patients transitioning from the hospital or emergency department back home. This telemonitoring service offers remote monitoring of patients (24/7/365 available nurse, personalized preventive and educational intervention tailored to each individual, medication adherence checks, monthly phone check-ups, follow-up scheduling with pharmacist, physician and/or other health professionals) and includes a customized emergency response intervention when patients are in need. This service supports the autonomy of frail elderly patients living at home. It also consists of a network of community-based volunteer caregivers who are notified to visit patients when in need or simply to conduct a routine check-up.

The ACE Collaborative will 1) implement the ACE CTI Program; 2) implement a balanced scorecard tailored to the CISSS CA to track performance on a number of performance indicators at the patient, caregiver, provider and system levels; and 3) develop the CISSS CA’s own organizational collaborative peer-to-peer coaching capacity (using our Wiki-suite) to position our centre as a leader in the dissemination of elder-friendly care practices within our region (Chaudière-Appalaches). The 12-month ACE Collaborative comes with: 1) CFHI collaborative support for implementation, evaluation and spread of proven evidence-informed elder-friendly care practices; 2) peer-to-peer networking and exchange among the entire cohort; 3) monthly team educational webinars; 4) support for performance measurement; 5) an in-person workshop to foster cross-team learning and sharing; 6) access to a network of expert coaches, including Dr. Sinha and his team who led the ACE Program at Mount Sinai.

Specific objectives for Phase I: Our objectives will be to: 1) consult potential stakeholders (clinicians, patients, and health managers) to determine needs, barriers and suggestions to adapting the ACE CTI for the CISSS CA; 2) adapt the ACE CTI and its knowledge tools to the needs/barriers of local patients and health professionals; 3) implement the ACE CTI at one site within the CISSS CA (Hôtel-Dieu de Lévis); and 4) measure uptake of the ACE CTI and changes to patient-, caregiver- and system-level outcomes after implementation.

Methods: Phase IA (Planning): An executive committee led by Patrick Archambault and Josée Rivard (Director of Nursing) will meet every two weeks during the 12-month collaborative. The six other members will be a transition coach, telemonitoring nurse, ED Director, ED Head nurse, geriatric specialist and a patient representative. An extended ACE CTI team including members from the ED, geriatric acute care unit, hospital administration and community representatives will meet monthly (see Table 4 in additional file).

Phase IB (Wiki101 training): Our executive committee and extended team members will complete the Wiki101 online and classroom training modules (see Figure 5 in additional file) to learn how to navigate and edit knowledge tools in WikiTrauma. We will also train emergency physicians, geriatricians, family physicians, nurses (ward, home care and telemonitoring) and social workers about how to navigate and provide feedback on our wiki-based ACE knowledge tools. We will track the number participants having completed Wiki101 and ask participants to note the time spent completing this training.

Phase IC (Adaptation of the ACE knowledge tools): We will use WikiTrauma to house the original versions of the knowledge tools provided by the Mount Sinai ACE program and collaborate with knowledge users to create a new set adapted for use in the CISSS CA. We will also create new knowledge tools as needed during implementation of the ACE program. As the project evolves, we will present the program and our context-adapted tools to the various community-based and hospital-based stakeholders and consult them about their needs to maximise their buy-in with this program and its tools. All team members will be asked to make suggestions directly in WikiTrauma. These comments will be reviewed during our bi-monthly team meetings and integrated after peer review by the executive committee to insure reliability. ACE Program leaders at the Mount Sinai/CFHI/TVN will also have access to these online tools to provide expert oversight of our tool adaptation and creation process. For new patient-centered knowledge tools (e.g. self-care management guides), we will solicit feedback from our patient representative, Mme Poiré, who will lead a subcommittee of 6 caregivers and patients from the CISSS CA Users Committee. Focus groups will solicit in-person feedback for more in-depth feedback. Finally, frail elderly patients will give feedback during regular care using paper versions of our tools. We will document feedback in detail including time spent providing it. Throughout the 12 months, continuous improvements and adjustments will be made to our wiki-based KT tools by team members and health professionals using them. Our wiki will track these changes automatically and we will also use a Google Analytics account to track the use of the tools throughout the year.

Phase ID (Study design and set up): To study the impact of our context-adapted ACE CTI Program, we will conduct a before and after implementation trial with a 3-month baseline control group cohort and a 3-month post-intervention cohort. Eligible patients will: i) be aged ≥65 years; ii) be slated for discharge from an acute care hospital or the ED; iii) be rated ≥ 4 on the Canadian Study of Health and Aging-Clinical Frailty scale (CSHA-CFS); iv) be able to understand and read French or English; and v) be able to give informed consent. For clients who cannot provide informed consent or read, their authorized caregiver will give proxy consent. The research team will recruit in a consecutive manner by conducting daily AM screening of lists of hospitalized patients or ED patients aged 65 and older. A trained research assistant will assess the CSHA-CFS score and eligibility. We will keep detailed information on the flow of clients throughout the trial. All participants (providers, clients and caregivers) will sign consent forms approved by the ethics boards of the CISSS CA. Baseline data will be collected on age, sex, race, language, education level, family income, pre-hospital living situation (e.g. home, apartment, intermediate nursing homes, etc.), geography (rural vs urban: as defined by Statistics Canada for Rural and Small Town (120)), access to Internet, use of technology (mobile phone, tablet, computer), reason for hospital admission/consultation in ED, quality of life at admission (HR-QoL using 2 subscales from the Nottingham Health Profile: Social Isolation and Emotional Reactions (121-124)), CSHA-CFS (43,125-126), functional autonomy measured by the Older Americans Resources and Services (OARS) Activities of Daily Living (ADL) Scale (127-129), and Caregiver Burden Index (130-131).

At discharge, we will note: 1) destination, 2) final diagnoses for hospital admission or ED consultation, and 3) length of hospital and ED stay. After discharge, telephone follow-up will be performed at: 1) 48 hours to perform the Care Transition Measure (1) and verify uptake of all ACE CTI interventions; and 2) 30 days to measure the OARS ADL score and functional decline (defined as a drop in 3 points on the 28-point OARS ADL score (132)). At 30-day follow-up, we will also verify the following data: 1) current living situation, 2) ED visits, 3) number of primary care provider visits (e.g. physician or advance practice nurse) and reasons for visit, 2) OARS ADL score, 3) HR-QoL (Social Isolation and Emotional Reactions subscales); and 4) Caregiver Burden Index. Medical records and administrative hospital databases will be verified to calculate hospital-level outcomes for patients aged ≥65 years for periods before and after our intervention: 1) number of ED visits, 2) rate of hospital readmission, 3) overall ED admission rate, 4) alternate level care days, and 5) rate of patients returning home as opposed to other institutional settings. Once our post-intervention observation period will be completed, we will continue to monitoring the following monthly hospital-level ACE performance indicators using the current hospital administrative databases for the complete duration of this program: 1) ED visits, 2) hospital readmission rate, 3) ED admission rate, 4) alternate level care days.

To calculate costs (ACE CTI Program, Wiki-suite intervention, telemonitoring service) and potential cost-savings, we will document resource use (time spent, salary). The telemonitoring administrative database will document the number of telemonitoring interventions (phone calls, emergency response interventions, volunteer visits) occurring during the 3-month study period. Patient expenses (telemonitoring equipment and monthly service fee) and the CISSS CA expenses (salaries for 24/7 telemonitoring nurses) will be documented. We will also ask the ACE CTI implementation team members to keep a logbook to track hours spent on 1) administration and data collection for this study, 2) time spent in Wiki101 training during study setup, 3) time spent to adapt/create knowledge tools, and 3) time spent with patients (transitions coach).

Phase IE (Implementation): After the training in using the context-adapted ACE CTI KT tools, we will set an official start date for patient recruitment and encouraging health professionals to use of our context-adapted tools with patients. Patients in the intervention cohort will be recruited to receive our context-adapted ACE Care Transitions Intervention. This intervention will include 1) sending a discharge summary to their primary care provider, 2) planning a follow-up appointment with their family physician, 3) assigning a transition coach for a 30-day transition period, 4) pre- and post-hospitalization medication list reconciliation, 5) offering access to our context-adapted patient-oriented KT tools, 5) access to the CISSS CA telemonitoring program.

Phase IF (Analysis): Our primary outcome of interest will be the quality of care transition from hospital to the community using the Care Transition Measure, a 12 item self-report questionnaire administered by phone 48h after hospital/ED discharge (133). Secondary outcomes will be: 1) living situation, 2) length of hospital/ED stay, 3) functional decline, 4) quality of life, 5) burden of care, 5) number of ED visits, 6) the rate of hospital readmission, 7) overall ED admission rate, 8) alternate level care days, 9) rate of patients returning home as opposed to other institutional settings; 10) uptake of the ACE CTI, and 11) cost of the various elements of our intervention. We will compare the change in hospital-level averages for each of these variables before and after intervention. Initial 2-sample comparisons of the intervention and control groups will be conducted using appropriate statistical tests (e.g. Wilcoxon rank sum test for non-normally distributed continuous variables and Fisher exact test for dichotomous variables). The χ2 test will be used for dichotomous outcomes testing statistical significance between the intervention and control groups. Logistic regression analysis will be used to adjust for possible imbalances in baseline characteristics. Considering the premises (alpha=0.05, beta=0.8, standard deviation=16 (133)), we will need a sample of 64 patients in each cohort to detect a minimally clinical important difference of 8 for the CTM measure (ranging from 0 to 100).

Potential difficulties: 1) Low recruitment rates of patients with cognitive, hearing or visual impairments could limit the external validity of our results. Proxy consent from caregivers will be used to optimize the participation in our study. 2) Lack of blinding may positively impact our primary and secondary outcomes. Although we acknowledge this limitation, data analysis will be conducted blinded to group assignment.

Expected outcomes: We expect to: 1) create a set of wiki-based contextualized knowledge tools to support the implementation of the ACE Collaborative in the CISSS CA; 2) improve the quality of care transitions for elderly patients; and 3) increase our understanding of using the Wiki-suite to adapt knowledge tools to local contexts.

ÉCHÉANCIER

Timelines for the 4 proposed research phases.

F=Fall, W=Winter, S=Summer