Comparison of the effectiveness of “care transition intervention” plan and routine care plan on health-related outcomes in the older adults with multiple chronic condition

Comparison of the effectiveness of “care transition intervention” plan and routine care plan on health-related outcomes in the older adults with multiple chronic condition

Clinical trial with control group, with parallel groups, randomized on 90 patients. For randomization, the permutation block randomization technique will be used.

The study is an interventional study with a controlled and randomized clinical trial design with two intervention and control groups that will be performed in Imam Khomeini Hospital in Sari affiliated to Mazandaran University of Medical Sciences.

Inclusion criteria include: Age 60 years and older, Alertness and ability to communicate, Normal cognition, Having at least two Chronic condition, Having a telephone, Being transported home after discharge from hospital, Family caregivers must be at least 18 years old. Non-Inclusion include: Evidence of mental illness and dementia

In the experimental group, the intervention is based on the care transition intervention model, which is the duration of the intervention from the time of patient admission to the hospital to 30 days after discharge. In general, the transition coach will perform the care transition intervention in three stages: 1- hospital visit, 2- home visit and 3- at least three telephone calls, with the participation of the patient and the caregiver. In the control group, the researcher does not intervene during the research period. The control group receives the routine hospital care.

Rehospitalization- Quality of Life - Activity of Daily Living - Instrumental Activity of Daily Living - Depression

Sample allocation is done randomly (lottery) in two study groups, so that an allocation protocol is created using the permuted block randomization technique (Pocock, 2013). Since the sample framework or patient list is not clear and available before admission, 90 cards are first numbered for the 90 participants and placed in a basket. The cards are then randomly removed from the basket and placed in two intervention and control envelopes. Then, the eligible patients are assigned a number based on the order of admission to the hospital, and then, based on their placement in the replaced blocks, they are selected sequentially and placed in an intervention group or a control group. This ensures the random allocation of participants.