Focusing on Frailty: How One Research Team Came Together to Study Older Adults' Transition from Hospital to Home

In plain language, what is your project about? What questions are you trying to answer by doing this research?

With Canada’s aging population, it is more important than ever that health and social services are able to provide proper care for frail older adults. This is particularly true in New Brunswick (NB), where the number of seniors is growing quickly. Frail older adults often have multiple interacting vulnerable conditions related to their health, function, cognition and psycho-social needs.
 
One specific challenge in providing care is that most older adults prefer to stay in their own homes as long as possible. To set them up for success, health and social care providers must adequately identify all of their needs, and then coordinate the appropriate professionals from a range of services, to support their continued life at home and in the community. ​

This is an especially challenging task, though, for those health care professionals based in hospitals and providing specialized geriatric care. They work mostly with frail older adults who have recently been in hospital with multiple challenges medically, functionally, cognitively and socially.  To plan a successful hospital discharge and transition back home is made more complex by their increased frailty.
 
In our study, we looked at the processes involved in transitioning frail older adults from specialized geriatric hospital units back to their homes in the community, in three New Brunswick cities. We also spoke with frail older adults and health care professionals about their experiences in navigating the transition from hospital to home.
 
To guide our research, we asked:

• Who should be involved in preparing patients to return home following a hospital admission?
• What needs to be considered when planning a hospital discharge?
• What are the strengths and the vulnerabilities in the processes we currently have? and
• What factors impact carrying out transitional plans for frail older adults?

 
Our goal is to develop practical recommendations for policy makers and clinicians on how to have successful hospital-to-home transitions for frail older adults, which will help them and their families.

Looking at your research team members, there are people from other departments and institutions. Have you worked together before this project?

Several of our research team members have worked together on numerous projects, while others were new collaborators.
 
Drs. McCloskey, Jarrett, McGibbon, and Scheme have worked together in many previous studies, focusing on older adult care. Other team members have worked together, in various combinations, on studies also related to older adult care.

​Team members from Horizon Health (including Drs. Feltmate, MacDonald, both geriatricians, and Dr. Yetman), and from Medavie (Beth Harris), were welcome additions who brought additional perspectives to the project team. 

Dr. Hanson and the SOAR team from Horizon Health (Leanne Skerry and Emily Kervin) provided general research support by advising on proposed methods, managing data collection, and preparing the team’s knowledge translation. Samantha Fowler joined the team to also assist with knowledge translation, using the connections of the Maritime SPOR SUPPORT Unit.

Dr. Veitch and his team from Memorial University were new collaborators, but had previous work involving engineering mapping software (FRAM) in the context of health research

Patients, family members and front-line staff were involved in every aspect of this study, including its design and implementation. Not only did we want to ensure that our research would be relevant to stakeholders, we wanted people to have a voice in how transitional care is organized and delivered in New Brunswick.

Dr. Rose McCloskey

Dr. Pam Jarrett

Dr. Natasha Hanson

How – if at all – has the COVID-19 pandemic changed your research project and/or collaboration?

Fortunately, we completed our data collection and analysis prior to the onset of the COVID-19 pandemic. However, it has impacted our knowledge translation plan. Conferences we targeted to present our results have been largely cancelled, and journal submissions of articles have had longer timelines for review. Also, any meetings we would like to plan with policy makers have been delayed until COVID-19 is further under control, as clearly that is the current focus of attention.  

What advice would you give to others on building a successful research collaboration?

Bring together as many diverse professionals and perspectives together as possible. Because our collaboration brings together various clinical and academic experts under one common goal, we were able to share our respective knowledge throughout the design and implementation of the project. This continuous exchange of ideas enhanced our project tremendously. As well, the interdisciplinary collaboration let to a successful research funding application, because we were proposing a unique and diverse approach to analyze a complex clinical area.
 
Speaking of funding: starting with a grant application is a great way to focus potential projects. An application allowed for us to clearly discuss and define our individual roles, responsibilities and requirements for funding– who completes the data collection, who analyzes the data, who drafts the manuscripts, etc. So, we would also suggest that collaborating in a focused way is key to being successful in research.

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This project, Optimizing transitions from hospital to home for frail older adults: Examining how hospital discharge plans translate into supportive home care environments, was funded through a Canadian Frailty Network Catalyst Grant (CAT 2018-38). The team continues to prepare manuscripts for publication, and this space will be updated with references once published. 

​Rose McCloskey, RN, PhD
Professor, Dept. Nursing & Health Sciences, University of New Brunswick Saint John

Dr. Pamela Jarrett
Geriatrician, Dept. Geriatric Medicine, ​St. Joseph’s Hospital, Horizon Health Network

Dr. Patrick Feltmate
Geriatrician, Dr. Everett Chalmers Regional Hospital, Horizon Health Network

Dr. Jason MacDonald
Geriatrician, The Moncton Hospital, Horizon Health Network

​Natasha Hanson, BA, MA, PhD
Qualitative Methodologist, Research Services, Horizon Health Network

​Leanne Skerry, BSc, MA
Research Coordinator, Research Services, Horizon Health Network
​
Beth Harris, RN, MN
Clinical Nurse Specialist, Extramural Program, Medavie

​Linda Yetman, PhD
Research Coordinator, Dept. Geriatric Medicine, St. Joseph’s Hospital, Horizon Health Network

Samantha Fowler, BA, MA
Research Manager, Maritime SPOR SUPPORT Unit

Chris A. McGibbon, PhD
Professor, Faculty of Kinesiology and Institute of Biomedical Engineering, University of New Brunswick

Erik Scheme, PEng, PhD
NB Innovation Research Chair in Medical Devices and Technologies
Assistant Professor, Institute of Biomedical Engineering, University of New Brunswick

Brian Veitch, PhD
Faculty of Engineering and Applied Science, Memorial University