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Conference Abstracts

An integrated hospital-to-home transitional care intervention for older adults with multimorbidity and depressive symptoms: A pragmatic effectiveness-implementation trial


Rebecca Ganann

McMaster University, CA
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Older adults face increased risk of developing multimorbidity as they age, including experiencing higher levels of depressive symptoms compared to those without multimorbidity.  Older adults with multimorbidity often require care from different healthcare providers in several settings and are, therefore, susceptible to fragmented care. The risk for fragmented care is heightened when transitioning from hospital to home, leading to decreased health-related quality of life, increased readmission rates, decreased patient satisfaction and safety, and increased caregiver burden.  This study tested a novel integrated nurse-led intervention to improve the quality and experience of hospital-to-home transitions for older adults with depressive symptoms and multimorbidity. The intervention included usual care plus in-home visits and phone calls from a Registered Nurse (RN) over a 6-month period. The RN provided system navigation support, education, medication review, and evidence-based strategies to manage depressive symptoms and multimorbidity. 


This pragmatic randomized controlled trial examined the implementation, effectiveness and costs of an integrated nurse-led hospital-to-home transitional care intervention in three communities in Ontario, Canada.  Study participants (n=127) received the intervention (n=63) or usual care (n=64). Patient and caregiver partners were involved as co-researchers in designing, implementing and evaluating this project.  They informed selection of patient-relevant outcomes, development of study materials, adaptations to the intervention to meet local community needs, interpretation of findings, and knowledge translation. 


Participants were an average age of 76 years and had an average of 8 chronic conditions.  Findings suggest that the intervention was feasible and acceptable to participants and providers. Intervention group participants received an average of 5 visits and 6 phone calls. Intention-to-treat analyses using ANCOVA models showed no statistically significant group differences in outcomes, however, in the intervention group the upper 95% confidence interval for the mean group difference showed greater clinically significant improvements in physical functioning.  Quantile regression showed that the intervention may result in greater improvements in physical functioning for individuals with lower levels of baseline physical functioning and higher levels of perceived social support.  No statistically significant group differences were observed for service use or costs.


Since low physical functioning and perceived social support are linked to higher rates of hospital readmissions and death, components of this intervention may be integral to creating an optimal integrated transitional care model for older adults with multimorbidity, depressive symptoms and lower levels of physical functioning.


The results of this study may inform the delivery of more integrated and coordinated patient-centred care to improve health outcomes in this vulnerable population.

Lessons learned

Older adults with multimorbidity and depressive symptoms transitioning from hospital-to-home are susceptible to adverse events as a result of a poorly designed healthcare system. This study established the feasibility of a new intervention that has the potential to enhance health outcomes in this vulnerable population. 


The power of the study was not adequate to detect a significant difference due to sample size.

Suggestions for future research  

Future research is warranted to test the intervention in other diverse settings and populations.

How to Cite: Ganann R. An integrated hospital-to-home transitional care intervention for older adults with multimorbidity and depressive symptoms: A pragmatic effectiveness-implementation trial. International Journal of Integrated Care. 2021;21(S1):134. DOI:
Published on 01 Sep 2021.


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