Effectiveness of a nurse-led hospital-to-home transitional care intervention for older adults with multimorbidity and depressive symptoms: A pragmatic randomized controlled trial

Maureen Markle-Reid, Carrie McAiney, Kathryn Fisher, Rebecca Ganann, Alain P Gauthier, Gail Heald-Taylor, Janet E McElhaney, Fran McMillan, Penelope Petrie, Jenny Ploeg, Diana J Urajnik, Carly Whitmore, Maureen Markle-Reid, Carrie McAiney, Kathryn Fisher, Rebecca Ganann, Alain P Gauthier, Gail Heald-Taylor, Janet E McElhaney, Fran McMillan, Penelope Petrie, Jenny Ploeg, Diana J Urajnik, Carly Whitmore

Abstract

Objective: To evaluate the effectiveness of a nurse-led hospital-to-home transitional care intervention versus usual care on mental functioning (primary outcome), physical functioning, depressive symptoms, anxiety, perceived social support, patient experience, and health service use costs in older adults with multimorbidity (≥ 2 comorbidities) and depressive symptoms.

Design and setting: Pragmatic multi-site randomized controlled trial conducted in three communities in Ontario, Canada. Participants were allocated into two groups of intervention and usual care (control).

Participants: 127 older adults (≥ 65 years) discharged from hospital to the community with multimorbidity and depressive symptoms.

Intervention: This evidence-based, patient-centred intervention consisted of individually tailored care delivery by a Registered Nurse comprising in-home visits, telephone follow-up and system navigation support over 6-months.

Outcome measures: The primary outcome was the change in mental functioning, from baseline to 6-months. Secondary outcomes were the change in physical functioning, depressive symptoms, anxiety, perceived social support, patient experience, and health service use cost, from baseline to 6-months. Intention-to-treat analysis was performed using ANCOVA modeling.

Results: Of 127 enrolled participants (63-intervention, 64-control), 85% had six or more chronic conditions. 28 participants were lost to follow-up, leaving 99 (47 -intervention, 52-control) participants for the complete case analysis. No significant group differences were seen for the baseline to six-month change in mental functioning or other secondary outcomes. Older adults in the intervention group reported receiving more information about health and social services (p = 0.03) compared with the usual care group.

Conclusions: Although no significant group differences were seen for the primary or secondary outcomes, the intervention resulted in improvements in one aspect of patient experience (information about health and social services). The study sample fell below the target sample (enrolled 127, targeted 216), which can account for the non-significant findings. Further research on the impact of the intervention and factors that contribute to the results is recommended.

Trial registration: clinicaltrials.gov Identifier: NCT03157999.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1. Study flow diagram.
Fig 1. Study flow diagram.
Fig 2. Interpreting 95% confidence intervals for…
Fig 2. Interpreting 95% confidence intervals for PCS and MCS (“inconclusive findings”).
Note: MID: minimally important difference.
Fig 3. Quantile regression results: Baseline to…
Fig 3. Quantile regression results: Baseline to six-month change in PRQ.

References

    1. Birk JL, Kronish IM, Moise N, Falzon L, Yoon S, Davidson KW. Depression and multimorbidity: Considering temporal characteristics of the associations between depression and multiple chronic diseases. Health Psychol. 2019;38(9):802–11. Epub 2019/04/22. doi: 10.1037/hea0000737 .
    1. Marengoni A, Angleman S, Melis R, Mangialasche F, Karp A, Garmen A, et al.. Aging with multimorbidity: a systematic review of the literature. Ageing research reviews. 2011;10(4):430–9. Epub 2011/03/16. doi: 10.1016/j.arr.2011.03.003 .
    1. van den Bussche H, Koller D, Kolonko T, Hansen H, Wegscheider K, Glaeske G, et al.. Which chronic diseases and disease combinations are specific to multimorbidity in the elderly? Results of a claims data based cross-sectional study in Germany. BMC public health. 2011;11:101. Epub 2011/02/16. doi: 10.1186/1471-2458-11-101 ; PubMed Central PMCID: PMC3050745.
    1. Feely A, Lix LM, Reimer K. Estimating multimorbidity prevalence with the Canadian Chronic Disease Surveillance System. Health Promot Chronic Dis Prev Can. 2017;37(7):215–22. Epub 2017/07/14. doi: 10.24095/hpcdp.37.7.02 ; PubMed Central PMCID: PMC5650032.
    1. Ward BW, Schiller JS. Prevalence of multiple chronic conditions among US adults: estimates from the National Health Interview Survey, 2010. Prev Chronic Dis. 2013;10:E65. Epub 2013/04/27. doi: 10.5888/pcd10.120203 ; PubMed Central PMCID: PMC3652717.
    1. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet (London, England). 2012;380(9836):37–43. Epub 2012/05/15. doi: 10.1016/s0140-6736(12)60240-2 .
    1. Koné Pefoyo AJ, Bronskill SE, Gruneir A, Calzavara A, Thavorn K, Petrosyan Y, et al.. The increasing burden and complexity of multimorbidity. BMC public health. 2015;15(1):415. doi: 10.1186/s12889-015-1733-2
    1. King DE, Xiang J, Pilkerton CS. Multimorbidity Trends in United States Adults, 1988–2014. The Journal of the American Board of Family Medicine. 2018;31(4):503–13. doi: 10.3122/jabfm.2018.04.180008
    1. Chatterji S, Byles J, Cutler D, Seeman T, Verdes E. Health, functioning, and disability in older adults—present status and future implications. Lancet (London, England). 2015;385(9967):563–75. Epub 2014/12/04. doi: 10.1016/S0140-6736(14)61462-8 ; PubMed Central PMCID: PMC4882096.
    1. Salisbury C, Man MS, Bower P, Guthrie B, Chaplin K, Gaunt DM, et al.. Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach. Lancet (London, England). 2018;392(10141):41–50. Epub 2018/07/03. doi: 10.1016/S0140-6736(18)31308-4 ; PubMed Central PMCID: PMC6041724.
    1. Kastner M, Cardoso R, Lai Y, Treister V, Hamid JS, Hayden L, et al.. Effectiveness of interventions for managing multiple high-burden chronic diseases in older adults: a systematic review and meta-analysis. CMAJ. 2018;190(34):E1004–E12. Epub 2018/08/29. doi: 10.1503/cmaj.171391 ; PubMed Central PMCID: PMC6110649 the Canadian Institutes of Health Research and the Government of Ontario during the conduct of the study; he also reports receiving personal fees from Diabetes Canada, outside the submitted work. Noah Ivers held a volunteer position as Chair of the Ontario Vascular Coalition, which envisioned a multicondition approach to management of chronic diseases and risk factors in primary care. Sharon Marr reports a patent issued for the trademark for the Geriatric Certificate program (February 2013). Geoff Wong reports that his salary is partly supported by The Evidence Synthesis Working Group of the National Institute for Health Research School for Primary Care Research (Project Number 390). He is Deputy Chair of the UK National Institute of Health Research Health Technology Assessment Out-of-Hospital Panel. No other competing interests were declared.
    1. 2018 World Population Data Sheet With Focus on Changing Age Structures â Population Reference Bureau 2018. Available from: .
    1. Sinnige J, Braspenning J, Schellevis F, Stirbu-Wagner I, Westert G, Korevaar J. The prevalence of disease clusters in older adults with multiple chronic diseases—a systematic literature review. PloS one. 2013;8(11):e79641. Epub 2013/11/19. doi: 10.1371/journal.pone.0079641 ; PubMed Central PMCID: PMC3823581.
    1. Read JR, Sharpe L, Modini M, Dear BF. Multimorbidity and depression: A systematic review and meta-analysis. Journal of affective disorders. 2017;221:36–46. Epub 2017/06/20. doi: 10.1016/j.jad.2017.06.009 .
    1. Padayachey U, Ramlall S, Chipps J. Depression in older adults: prevalence and risk factors in a primary health care sample. South African Family Practice. 2017;59(2):61–6. doi: 10.1080/20786190.2016.1272250
    1. Unützer J, Patrick DL, Diehr P, Simon G, Grembowski D, Katon W. Quality adjusted life years in older adults with depressive symptoms and chronic medical disorders. International psychogeriatrics. 2000;12(1):15–33. Epub 2000/05/08. doi: 10.1017/s1041610200006177 .
    1. Bock JO, Luppa M, Brettschneider C, Riedel-Heller S, Bickel H, Fuchs A, et al.. Impact of depression on health care utilization and costs among multimorbid patients—from the MultiCare Cohort Study. PloS one. 2014;9(3):e91973. Epub 2014/03/19. doi: 10.1371/journal.pone.0091973 ; PubMed Central PMCID: PMC3956806.
    1. Strauss R, Kurdyak P, Glazier RH. Mood Disorders in Late Life: A Population-based Analysis of Prevalence, Risk Factors, and Consequences in Community-dwelling Older Adults in Ontario. Canadian journal of psychiatry Revue canadienne de psychiatrie. 2020:706743720927812-.
    1. Blazer DG. Depression in Late Life: Review and Commentary. The Journals of Gerontology: Series A. 2003;58(3):M249–M65. doi: 10.1093/gerona/58.3.m249
    1. Voinov B, Richie WD, Bailey RK. Depression and chronic diseases: it is time for a synergistic mental health and primary care approach. The primary care companion for CNS disorders. 2013;15(2). Epub 2013/08/10. doi: 10.4088/PCC.12r01468 ; PubMed Central PMCID: PMC3733529.
    1. Albrecht JS, Gruber-Baldini AL, Hirshon JM, Brown CH, Goldberg R, Rosenberg JH, et al.. Depressive symptoms and hospital readmission in older adults. Journal of the American Geriatrics Society. 2014;62(3):495–9. Epub 2014/02/12. doi: 10.1111/jgs.12686 ; PubMed Central PMCID: PMC3959240.
    1. Buja A, Claus M, Perin L, Rivera M, Corti MC, Avossa F, et al.. Multimorbidity patterns in high-need, high-cost elderly patients. PloS one. 2018;13(12):e0208875–e. doi: 10.1371/journal.pone.0208875 .
    1. Neiterman E, Wodchis WP, Bourgeault IL. Experiences of older adults in transition from hospital to community. Can J Aging. 2015;34(1):90–9. doi: 10.1017/S0714980814000518 .
    1. Mesteig M HJ, Sletvold O, Rosstad T, Saltvedt I. Unwanted incidents during transition of geriatric patients from hospital to home: a prospective observational study. BMC Health Serv Res. 2010;10(1):1–9. doi: 10.1186/1472-6963-10-1
    1. Storm M SI, Laugaland J, Dyrstad DN, Aase K. Quality in transitional care of the elderly: Key challenges and relevant improvement measures. Int J Integr Care. 2014;8(14):e013. doi: 10.5334/ijic.1194
    1. Forster AJ, Clark HD, Menard A, Dupuis N, Chernish R, Chandok N, et al.. Adverse events among medical patients after discharge from hospital. Canadian Medical Association Journal. 2004;170(3):345–9.
    1. Manderson B, McMurray J, Piraino E, Stolee P. Navigation roles support chronically ill older adults through healthcare transitions: a systematic review of the literature. Health Soc Care Community. 2012;20(2):113–27. Epub 2011/10/15. doi: 10.1111/j.1365-2524.2011.01032.x .
    1. Gruneir A, Fung K, Fischer HD, Bronskill SE, Panjwani D, Bell CM, et al.. Care setting and 30-day hospital readmissions among older adults: a population-based cohort study. Cmaj. 2018;190(38):E1124–e33. Epub 2018/09/27. doi: 10.1503/cmaj.180290 ; PubMed Central PMCID: PMC6157496 Innovations Branch of the Ontario Ministry of Health and Long-Term Care. No other competing interests were declared.
    1. Kiran T, Wells D, Okrainec K, Kennedy C, Devotta K, Mabaya G, et al.. Patient and caregiver priorities in the transition from hospital to home: results from province-wide group concept mapping. BMJ Qual Saf. 2020;29(5):390–400. Epub 2020/01/08. doi: 10.1136/bmjqs-2019-009993 .
    1. Jeffs L, Dhalla I, Cardoso R, Bell CM. The perspectives of patients, family members and healthcare professionals on readmissions: preventable or inevitable? J Interprof Care. 2014;28(6):507–12. Epub 2014/06/11. doi: 10.3109/13561820.2014.923988 .
    1. Ontario HQ. Transitions Between Hospital and Home—Health Quality Ontario (HQO) 2020. Available from: .
    1. Almborg AH UK, Thulin A, Berg S. Patients’ perceptions of their participation in discharge planning after acute stroke. J Clin Nurs. 2009;18(2):199–209. doi: 10.1111/j.1365-2702.2008.02321.x
    1. Sheikh F GE, Bellatoni M, Christmas C, Lafreniere JP, Arbaje AI. A call to bridge across silos during care transitions. The Joint Commission Journal on Quality and Patient Safety. 2018;44(5):270–8. doi: 10.1016/j.jcjq.2017.10.006
    1. Lowthian J. How do we optimise care transition of frail older people? Age Ageing. 2017;46(1):2–4. doi: 10.1093/ageing/afw171
    1. Hudson R CL, Whichello R. Transitions in a wicked environment. J Nurs Manag. 2014;22(2):201–10. doi: 10.1111/j.1365-2834.2012.1478.x
    1. Bauer M FL, Haesler E, Manfrin M. Hospital discharge planning for frail older people and their family. Are we delivering best practice? A review of the evidence. J Clin Nurs. 2009;18(18):2539–46. doi: 10.1111/j.1365-2702.2008.02685.x
    1. Jerant AF vF-FM, Moore M. Patients’ perceived barriers to active self-management of chronic conditions. Patient Educ Couns. 2005;57(3):300–7. doi: 10.1016/j.pec.2004.08.004
    1. Schulman-Green D, Jaser SS, Park C, W R. A metasynthesis of factors affecting self-management of chronic illness. J Adv Nurs. 2016;72(7):1469–89. doi: 10.1111/jan.12902
    1. Lapointe-Shaw L, Mamdani M, Luo J, Austin PC, Ivers NM, Redelmeier DA, et al.. Effectiveness of a financial incentive to physicians for timely follow-up after hospital discharge: a population-based time series analysis. Cmaj. 2017;189(39):E1224–e9. Epub 2017/10/04. doi: 10.1503/cmaj.170092 ; PubMed Central PMCID: PMC5628034 advisory board member to AstraZeneca, Bristol-Myers Squibb, Eli Lilly and Company, GlaxoSmithKline, Hoffman–La Roche, Novartis, Novo Nordisk and Pfizer. Noah Ivers and Muhammad Mamdani have received research grants from the Ontario Ministry of Health and Long-Term Care, unrelated to the current study. Chaim Bell has received consultant fees from the Policy and Innovation Branch of the Ontario Ministry of Health and Long-Term Care. No other competing interests were declared.
    1. Bucknall TK, Hutchinson AM, Botti M, McTier L, Rawson H, Hitch D, et al.. Engaging patients and families in communication across transitions of care: An integrative review. Patient Education and Counseling. 2020;103(6):1104–17. doi: 10.1016/j.pec.2020.01.017
    1. Naylor MD, Hirschman KB, apos, Connor M, Barg R, Pauly MV. Engaging older adults in their transitional care: what more needs to be done? Journal of Comparative Effectiveness Research. 2013;2:457+. doi: 10.2217/cer.13.58
    1. Ganann R, McAiney C, Johnson W. Engaging older adults as partners in transitional care research. Cmaj. 2018;190(Suppl):S40–s1. Epub 2018/11/09. doi: 10.1503/cmaj.180396 ; PubMed Central PMCID: PMC6472453.
    1. Greysen SR, Harrison JD, Kripalani S, Vasilevskis E, Robinson E, Metlay J, et al.. Understanding patient-centred readmission factors: a multi-site, mixed-methods study. BMJ Qual Saf. 2017;26(1):33–41. Epub 2016/01/16. doi: 10.1136/bmjqs-2015-004570 .
    1. Naylor MD, Hirschman KB, Toles MP, Jarrín OF, Shaid E, Pauly MV. Adaptations of the evidence-based Transitional Care Model in the U.S. Social science & medicine (1982). 2018;213:28–36. Epub 2018/07/29. doi: 10.1016/j.socscimed.2018.07.023 .
    1. Brown EL MG, Raue PJ, Moses S, Bruce ML. Recognition of depression among elderly recipients of home care services. Psychiatr Serv. 2003;54(2):208–13. doi: 10.1176/appi.ps.54.2.208
    1. Ell K UJ, Aranda M, Sanchez K, Lee PJ. Routine PHQ-9 depression screening in home health care: depression, prevalence, clinical and treatment characteristics and screening implementation. Home Health Care Serv Q. 2005;24(4):1–19. doi: 10.1300/J027v24n04_01
    1. Briggs R TK, Kenny RA, Kennelly SP. What is the prevalence of untreated depression and death ideation in older people? Data from the Irish Longitudinal Study on Aging. Int Psychogeriatrics. 2018;30(9):1393–401. doi: 10.1017/S104161021700299X
    1. McGilton KS, Vellani S, Yueung L, Chishtie J, Commisso E, Ploeg J, et al.. Identifying and understanding the health and social care needs of older adults with multiple chronic conditions and their caregivers: A scoping review. BMC Geriatrics. 2018;231. doi: 10.1186/s12877-018-0925-x
    1. Lam K, Abrams HB, Matelski J, Okrainec K. Factors associated with attendance at primary care appointments after discharge from hospital: a retrospective cohort study. CMAJ open. 2018;6(4):E587–e93. Epub 2018/12/05. doi: 10.9778/cmajo.20180069 ; PubMed Central PMCID: PMC6277252 Karen Okrainec sits on advisory committees for Health Quality Ontario on care transitions and is principal investigator for a study evaluating the affect of a patient-oriented discharge summary on patient experience and health care use after discharge. No other competing interests were declared.
    1. Markle-Reid M, McAiney C, Forbes D, Thabane L, Gibson M, Browne G, et al.. An interprofessional nurse-led mental health promotion intervention for older home care clients with depressive symptoms. BMC Geriatr. 2014;14:62. Epub 2014/06/03. doi: 10.1186/1471-2318-14-62 ; PubMed Central PMCID: PMC4019952.
    1. Blewett LA JK, McCarthy T, Lackner T, Brandt B. Improving geriatric transitional care through inter-professional care teams. Journal of Evaluation in Clinical Practice. 2010;16(1):57–63. doi: 10.1111/j.1365-2753.2008.01114.x
    1. Coburn KD MS, Lazansky R, Keller M, Davis N. Effect of a community-based nursing intervention on mortality in chronically ill older adults: a randomized controlled trial. PLoS Med. 2012;9(7):e1001265. doi: 10.1371/journal.pmed.1001265
    1. Finlayson K, Chang AM, Courtney MD, Edwards HE, Parker AW, Hamilton K, et al.. Transitional care interventions reduce unplanned hospital readmissions in high-risk older adults. BMC Health Serv Res. 2018;18(1):956. doi: 10.1186/s12913-018-3771-9
    1. Redmond P, Grimes TC, McDonnell R, Boland F, Hughes C, Fahey T. Impact of medication reconciliation for improving transitions of care (Review). Cochrane Database Syst Rev. 2018;(8). doi: 10.1002/14651858.CD013087
    1. Coleman EA, Parry C, Chalmers S, Min S-J. The Care Transitions Intervention: Results of a Randomized Controlled Trial. Arch Intern Med. 2006;166(17):1822–8. doi: 10.1001/archinte.166.17.1822
    1. Naylor MD. Transitional care for older adults: a cost-effective model. LDI Issue Briefs. 2004;9(6).
    1. Bryant-Lukosius D, Carter N, Reid K, Donald F, Martin-Misener R, Kilpatrick K, et al.. The clinical effectiveness and cost-effectiveness of clinical nurse specialist-led hospital to home transitional care: a systematic review. J Eval Clin Pract. 2015;21(5):763–81. Epub 2015/07/03. doi: 10.1111/jep.12401 .
    1. Le Berre M, Maimon G, Sourial N, Guériton M, Vedel I. Impact of Transitional Care Services for Chronically Ill Older Patients: A Systematic Evidence Review. Journal of the American Geriatrics Society. 2017;65(7):1597–608. doi: 10.1111/jgs.14828
    1. Toles M, Colón-Emeric C, Naylor MD, Barroso J, Anderson RA. Transitional care in skilled nursing facilities: a multiple case study. BMC Health Serv Res. 2016;16:186. Epub 2016/05/18. doi: 10.1186/s12913-016-1427-1 ; PubMed Central PMCID: PMC4869313.
    1. Weeks LE, Macdonald M, Martin-Misener R, Helwig M, Bishop A, Iduye DF, et al.. The impact of transitional care programs on health services utilization in community-dwelling older adults: a systematic review. JBI Database System Rev Implement Rep. 2018;16(2):345–84. Epub 2018/02/09. doi: 10.11124/JBISRIR-2017-003486 .
    1. Smith SM, Soubhi H, Fortin M, Hudon C, O’Dowd T. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database Syst Rev. 2012;(4):Cd006560. Epub 2012/04/20. doi: 10.1002/14651858.CD006560.pub2 .
    1. Royal College of Psychiatrists. Suffering in silence: Age inequality in older people’s mental health care. 2018.
    1. Cohen A, Houck PR, Szanto K, Dew MA, Gilman SE, Reynolds CF. Social inequalities in response to antidepressant treatment in older adults. JAMA Psychiatry. 2006;63(1):50–6. doi: 10.1001/archpsyc.63.1.50
    1. Sadana R, Blas E, Budhwani S, Koller T, Paraje G. Healthy ageing: Raising awareness of inequalities, determinants, and what could be done to improve health equity. The Gerontologist. 2016;56(2):S178–93. doi: 10.1093/geronto/gnw034
    1. Naylor MD, Shaid EC, Carpenter D, Gass B, Levine C, Li J, et al.. Components of Comprehensive and Effective Transitional Care. Journal of the American Geriatrics Society. 2017;65(6):1119–25. Epub 2017/04/04. doi: 10.1111/jgs.14782 ; PubMed Central PMCID: PMC5497308.
    1. Kansagara D, Chiovaro JC, Kagen D, Jencks S, Rhyne K, O’Neil M, et al.. Transitions of Care from Hospital to Home: An Overview of Systematic Reviews and Recommendations for Improving Transitional Care in the Veterans Health Administration. 2015.
    1. Vedel I, Khanassov V. Transitional Care for Patients With Congestive Heart Failure: A Systematic Review and Meta-Analysis. Ann Fam Med. 2015;13(6):562–71. doi: 10.1370/afm.1844 ; PubMed Central PMCID: PMC4639382.
    1. Verhaegh KJ, MacNeil-Vroomen JL, Eslami S, Geerlings SE, de Rooij SE, Buurman BM. Transitional care interventions prevent hospital readmissions for adults with chronic illnesses. Health Aff (Millwood). 2014;33(9):1531–9. doi: 10.1377/hlthaff.2014.0160 .
    1. Sox HC, Lewis RJ. Pragmatic trials: Practical answers to “real world” questions. JAMA Guide to Statistics and Methods. 2016;316(11):1205–6. doi: 10.1001/jama.2016.11409
    1. Zwarenstein M, Treweek S, Gagnier JJ, Altman DG, Tunis S, Haynes B, et al.. Improving the reporting of pragmatic trials: An extension of the CONSORT statement. BMJ. 2008;337. doi: 10.1136/bmj.a2390
    1. Markle-Reid M, McAiney C., Ganann R., Fisher K., Gafni A., Gauthier A. et al.. Study Protocol for a Hospital-to-Home Transitional Care Intervention for Older Adults with Multiple Chronic Conditions and Depressive Symptoms: A Pragmatic Effectiveness-Implementation Trial. BMC Geriatrics. (In Press). doi: 10.1186/s12877-020-01638-0
    1. Kroenke K, Spitzer RL, Williams JBW. The Patient Health Questionnaire-2: Validity of a two-item depression screener. Medical Care. 2003;41(11):1284–92. doi: 10.1097/01.MLR.0000093487.78664.3C
    1. Pfieffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. Journal of the American Geriatrics Society. 1975;23(10):433–41. doi: 10.1111/j.1532-5415.1975.tb00927.x
    1. National Institute of Mental Health. Center for Epidemiologic Studies Depression Scale (CES-D) Accessed 27 March 2020. Available from: .
    1. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. International journal of nursing studies. 2013;50(5):587–92. Epub 2012/11/20. doi: 10.1016/j.ijnurstu.2012.09.010 .
    1. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84(2):191–215. Epub 1977/03/01. doi: 10.1037//0033-295x.84.2.191 .
    1. Carter N, Valaitis RK, Lam A, Feather J, Nicholl J, Cleghorn L. Navigation delivery models and roles of navigators in primary care: a scoping literature review. BMC Health Services Research. 2018;18(1):96. doi: 10.1186/s12913-018-2889-0
    1. Canadian Coalition for Senior’s Mental Health. National guidelines for senior’s mental health: The assessment and treatment of depresssion. Toronto, ON: 2006.
    1. National Institute for Clinical Excellence. Depression: Management of depression in primary and secondary care. London: 2004.
    1. Kernick D, Chew-Graham CA, O’Flynn N. Clinical assessment and management of multimorbidity: NICE guideline. The British journal of general practice: the journal of the Royal College of General Practitioners. 2017;67(658):235–6. Epub 2017/04/30. doi: 10.3399/bjgp17X690857 ; PubMed Central PMCID: PMC5409424.
    1. Guiding principles for the care of older adults with multimorbidity: an approach for clinicians: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. Journal of the American Geriatrics Society. 2012;60(10):E1–e25. Epub 2012/09/22. doi: 10.1111/j.1532-5415.2012.04188.x ; PubMed Central PMCID: PMC4450364.
    1. Muth C, Blom JW, Smith SM, Johnell K, Gonzalez-Gonzalez AI, Nguyen TS, et al.. Evidence supporting the best clinical management of patients with multimorbidity and polypharmacy: a systematic guideline review and expert consensus. Journal of internal medicine. 2019;285(3):272–88. Epub 2018/10/26. doi: 10.1111/joim.12842 .
    1. Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al.. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ: British Medical Journal. 2014;348:g1687. doi: 10.1136/bmj.g1687
    1. Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, et al.. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation science: IS. 2015;10:21. Epub 2015/04/19. doi: 10.1186/s13012-015-0209-1 ; PubMed Central PMCID: PMC4328074.
    1. Institute CPS. Medication Reconciliation in Home Care 2019.
    1. Nezu AM, Nezu CM, D’Zurilla T. Solving life’s problems: a 5-step guide to enhanced well-being. New York, NY: Springer; 2007.
    1. Kramer RM, Hanna BA, Su S, Wei J. Collective identity, collective trust, and social capital: linking group identification and group cooperation. In: Turner ME, editor. Groups at Work: Theory and Research. 1 ed. New York: Psychology Press; 2014. p. 24.
    1. Strategy for Patient-Oriented Research—CIHR 2018 [updated 2018-06-18]. Available from: .
    1. National Committee for Quality Assurance. The Veterans Rand 12-item health survey Accessed 27 March 2020. Available from: .
    1. Kazis LE, Rogers WH, Rothendler J, Qian S, Selim A, Edelen MO, et al.. Outcome Performance Measure Development for Persons with Multiple Chronic Conditions: RAND Corporation; 2017.
    1. Irwin M, Artin KH, Oxman MN. Screening for depression in the older adult: criterion validity of the 10-item Center for Epidemiological Studies Depression Scale (CES-D). Arch Intern Med. 1999;159(15):1701–4. Epub 1999/08/17. doi: 10.1001/archinte.159.15.1701 .
    1. Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine. 2006;166(10):1092–7. doi: 10.1001/archinte.166.10.1092
    1. Löwe B, Decker O, Müller S, Brähler E, Schellberg D, Herzog W, et al.. Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population. Med Care. 2008;46(3):266–74. Epub 2008/04/05. doi: 10.1097/MLR.0b013e318160d093 .
    1. Weinert C, Brandt P. Measuring social support with the Personal Resource Questionnaire. Western Journal of Nursing Research. 1987;9(4):589–602. doi: 10.1177/019394598700900411
    1. Tawalbeh LI, Ahmad MM. Personal resource questionnaire: a systematic review. J Nurs Res. 2013;21(3):170–7. Epub 2013/08/21. doi: 10.1097/01.jnr.0000432049.31921.ab .
    1. Weinert C. Measuring Social Support: PRQ. In: Dilorio C, editor. Measurement of Nursing Outcomes: Self Care and Coping. 2 ed: Springer Publishing Company, 2003; 2003.
    1. de Witte L, Schoot T, Proot I. Development of the Client-Centred Care Questionnaire. Journal of Advanced Nursing. 2006;56(1):62–8. doi: 10.1111/j.1365-2648.2006.03980.x
    1. Teale EA, Young JB. A patient reported experience measure (PREM) for use by older people in community services. Age and Ageing. 2015;44(4):667–72. doi: 10.1093/ageing/afv014
    1. Brown G, Gafni A, Roberts J. Approach to the measurement of resource use and costs. Working paper. 2006.
    1. Browne G, Roberts J, Gafni A, Byrne C, Weir R, Majumdar B, et al.. Economic evaluations of community-based care: lessons from twelve studies in Ontario. J Eval Clin Pract. 1999;5(4):367–85. Epub 1999/12/01. doi: 10.1046/j.1365-2753.1999.00191.x .
    1. Browne G, Roberts J, Byrne C, Gafni A, Weir R, Majumdar B. The costs and effects of addressing the needs of vulnerable populations: results of 10 years of research. Can J Nurs Res. 2001;33(1):65–76. Epub 2002/04/04. .
    1. Markle-Reid M, Gafni A, Ploeg J, Fisher K, Ark P. Health and social service utilization costing manual. McMaster University: Aging, Community and Health Research Unit (ACHRU). 2015;Contract 001.
    1. Drummond M, Weatherly H, Ferguson B. Economic evaluation of health interventions. BMJ. 2008;337:a1204. doi: 10.1136/bmj.a1204
    1. Maruish ME eUsMftS-vHS, 3rd Ed. Lincoln, RI: QualityMetric Inc, 2012.
    1. Gewandter JS, McDermott MP, Kitt RA, Chaudari J, Koch JG, Evans SR, et al.. Interpretation of CIs in clinical trials with non-significant results: systematic review and recommendations. BMJ Open. 2017;7(7):e017288. Epub 2017/07/20. doi: 10.1136/bmjopen-2017-017288 ; PubMed Central PMCID: PMC5726092.
    1. Mental Component Summary. In: Preedy VR, Watson R.R., editor. Handbook of Disease Burdens and Quality of Life Measures. New York, NY: Springer; 2010.
    1. Lê Cook B, Manning WG. Thinking beyond the mean: a practical guide for using quantile regression methods for health services research. Shanghai Arch Psychiatry. 2013;25(1):55–9. doi: 10.3969/j.issn.1002-0829.2013.01.011 .
    1. Flom P. Quantile regression with PROC QUANTREG2011 November 5, 2020. Available from: .
    1. McNeish D. Missing data methods for arbitrary missingness with small samples. Journal of Applied Statistics. 2017;44(1):24–39. doi: 10.1080/02664763.2016.1158246
    1. Canadian Institutes of Health Research, Natural Sciences and Engineering Council of Canada, Social Sciences and Humanities Research Council of Canada. Tri-council policy statement: ethical conduct for research involving humans. Ottawa, Ontario: Government of Canada, 2018.
    1. Hopman WM, Towheed T, Anastassiades T, Tenenhouse A, Poliquin S, Berger C, et al.. Canadian normative data for the SF-36 health survey. Canadian Medical Association Journal. 2000;163(3):265–71.
    1. Loudon K, Treweek S, Sullivan F, Donnan P, Thorpe KE, Zwarenstein M. The PRECIS-2 tool: designing trials that are fit for purpose. Bmj. 2015;350:h2147. Epub 2015/05/10. doi: 10.1136/bmj.h2147 .
    1. Haines TP, Williams CM, Hill AM, McPhail SM, Hill KD, Brauer SG, et al.. Depressive symptoms and adverse outcomes from hospitalization in older adults: secondary outcomes of a trial of falls prevention education. Archives of gerontology and geriatrics. 2015;60(1):96–102. Epub 2014/12/03. doi: 10.1016/j.archger.2014.09.009 .
    1. Jansen YJFM, de Bont A, Foets M, Bruijnzeels M, Bal R. Tailoring intervention procedures to routine primary health care practice; an ethnographic process evaluation. BMC Health Services Research. 2007;7(1):125. doi: 10.1186/1472-6963-7-125
    1. Boult C, Leff B, Boyd CM, Wolff JL, Marsteller JA, Frick KD, et al.. A matched-pair cluster-randomized trial of guided care for high-risk older patients. Journal of general internal medicine. 2013;28(5):612–21. Epub 2013/01/12. doi: 10.1007/s11606-012-2287-y ; PubMed Central PMCID: PMC3631081.
    1. Brown JSL, Murphy C, Kelly J, Goldsmith K. How can we successfully recruit depressed people? Lessons learned in recruiting depressed participants to a multi-site trial of a brief depression intervention (the ‘CLASSIC’ trial). Trials. 2019;20(1):131. doi: 10.1186/s13063-018-3033-5
    1. Bower P, Brueton V, Gamble C, Treweek S, Smith CT, Young B, et al.. Interventions to improve recruitment and retention in clinical trials: a survey and workshop to assess current practice and future priorities. Trials. 2014;15:399. Epub 2014/10/18. doi: 10.1186/1745-6215-15-399 ; PubMed Central PMCID: PMC4210542.
    1. McDonald AM, Knight RC, Campbell MK, Entwistle VA, Grant AM, Cook JA, et al.. What influences recruitment to randomised controlled trials? A review of trials funded by two UK funding agencies. Trials. 2006;7:9. Epub 2006/04/11. doi: 10.1186/1745-6215-7-9 ; PubMed Central PMCID: PMC1475627.
    1. Mody L, Miller DK, McGloin JM, Freeman M, Marcantonio ER, Magaziner J, et al.. Recruitment and retention of older adults in aging research. Journal of the American Geriatrics Society. 2008;56(12):2340–8. doi: 10.1111/j.1532-5415.2008.02015.x .
    1. Smith SM, Wallace E, Salisbury C, Sasseville M, Bayliss E, Fortin M. A Core Outcome Set for Multimorbidity Research (COSmm). The Annals of Family Medicine. 2018;16(2):132–8. doi: 10.1370/afm.2178
    1. Ford I, Norrie J. Pragmatic Trials. The New England journal of medicine. 2016;375(5):454–63. Epub 2016/08/16. doi: 10.1056/NEJMra1510059 .
    1. Bull C, Byrnes J, Hettiarachchi R, Downes M. A systematic review of the validity and reliability of patient-reported experience measures. Health Serv Res. 2019;54(5):1023–35. Epub 2019/06/21. doi: 10.1111/1475-6773.13187 ; PubMed Central PMCID: PMC6736915.
    1. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759–69. Epub 2008/05/14. doi: 10.1377/hlthaff.27.3.759 .
    1. Bombard Y, Baker GR, Orlando E, Fancott C, Bhatia P, Casalino S, et al.. Engaging patients to improve quality of care: a systematic review. Implementation science: IS. 2018;13(1):98. Epub 2018/07/27. doi: 10.1186/s13012-018-0784-z ; PubMed Central PMCID: PMC6060529.
    1. Kuluski K, Peckham A, Gill A, Gagnon D, Wong-Cornall C, McKillop A, et al.. What is Important to Older People with Multimorbidity and Their Caregivers? Identifying Attributes of Person Centered Care from the User Perspective. International journal of integrated care. 2019;19(3):4–. doi: 10.5334/ijic.4655 .
    1. Chan B, Goldman LE, Sarkar U, Guzman D, Critchfield J, Saha S, et al.. High perceived social support and hospital readmissions in an older multi-ethnic, limited English proficiency, safety-net population. BMC Health Services Research. 2019;19(1):334. doi: 10.1186/s12913-019-4162-6

Source: PubMed

Sponsor e collaboratori

Condizioni mediche

Interventi farmacologici

3
Sottoscrivi