CHARM Study - Coordinating transitions from hospital for older adults with fractures: An interventional mixed methods study

About the project

Fall-related injuries, such as fractures, are increasing amongst older adults in New Brunswick, leading to hospitalizations and negative health effects. Transitions in care can be complicated and overwhelming for patients and families. Effective communication and coordination of care during these transitions are crucial. To improve inpatient care and the transitions in care, a Patient Navigator program was implemented. Trained professionals, Patient Navigators, helped to guide patients through the healthcare system. Older adult patients who were admitted with a fracture to a New Brunswick hospital’s Orthopedic Unit, along with their family caregivers, were approached to participate. Those patients who consented were randomly assigned to receive the Patient Navigator intervention (37 patients, 8  caregivers) or standard care (39 patients, 7 caregivers). This project evaluated the impact of the Patient Navigator program on: length of stay in acute care; unscheduled healthcare utilization post discharge; patient and family caregiver  experience and satisfaction with care; and HCP experiences working with Patient Navigators.

Conclusions and lessons learned

  • The patient navigator program shows promise for improving patient care transitions and post discharge care experiences by providing information, support and assistance to coordinate and access necessary services.
  • Results suggested that program benefits were greater among patients who were frail and/or who had less family support available.
  • According to interviews, patient navigators positively impacted the acute care experiences of patients and their family caregivers as well as their satisfaction with care after discharge from acute care.

Recommendations

  • Include patient navigator positions within clinical department reporting structures.
  • Address budgetary constraints for the hiring and training of patient navigators.
  • Integrate patient navigator services into the care and recovery pathway for older adults after a fracture, focusing on those who have higher levels of frailty and fewer familial/social supports.

To learn more read the complete project findings (PDF 140 KB)