Community Assets Supporting Transitions (CAST)

Summary

The aim of this study is to test a support program for older adults with symptoms of depression and other chronic health problems after they are discharged home from hospital. The study will be conducted in three communities in Ontario (Sudbury, Burlington, and Hamilton) and the program will be implemented with input from community members. The program will be delivered by a Registered Nurse, who will provide support to patients via home visits and telephone calls. The nurse's role will involve linking patients and their caregivers with needed services and supports, reviewing medications that the patients are taking, assessing patients' health, building the skills of patients in problem-solving and managing their care, and providing education to patients and their caregivers.

Conditions

• Comorbidity
• Depressive Symptoms

Interventions

BEHAVIORAL

Intervention group (CAST)

Intervention duration is expected to be 6 months. A full-time registered nurse (RN) will function as a Care Transitions Coordinator (CTC) who works collaboratively with one local hospital and other health and non-health representatives to deliver the intervention, which includes: * care coordination and system navigation (including facilitating timely primary care follow-up); * medication management; * assessing the needs and risk of the participants (including in-depth assessment of depressive symptoms); * evidence-based management of depressive symptoms and other chronic conditions to prevent the onset and worsening of other chronic conditions; * patient and caregiver education; and goal setting and problem-solving therapy.

Sponsors & Collaborators

• The Ontario Spor Support Unit

  collaborator OTHER

• Canadian Institutes of Health Research (CIHR)

  collaborator OTHER_GOV

• Institute for Clinical Evaluative Sciences

  collaborator OTHER

• Laurentian University

  collaborator OTHER

• The Labarge Optimal Aging Initiative

  collaborator OTHER

• McMaster University

  lead OTHER

Principal Investigators

• Maureen F Markle-Reid, Ph.D. · McMaster University

• Carrie McAiney, Ph.D. · University of Waterloo

Study Design

Allocation

RANDOMIZED

Purpose

OTHER

Masking

DOUBLE

Model

PARALLEL

Eligibility

Min Age

65 Years

Sex

ALL

Healthy Volunteers

No

Timeline & Regulatory

Start

2017-07-25

Primary Completion

2020-06-15

Completion

2020-06-15

Countries

• Canada

Study Locations