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      Building a Digital Bridge to Support Patient-Centered Care Transitions From Hospital to Home for Older Adults With Complex Care Needs: Protocol for a Co-Design, Implementation, and Evaluation Study

      , MA, PhD 1 , 2 , , , MD, PhD 3 , 4 , , MSc 1 , , MD 5 , , PhD 6 , , MSW, PhD 2 , 3 , , MD 4 , 7 , , MSc 3 , , BSc, MBA 3 , , PhD 8 , 9 , , MPH, MD, PhD 3 , , PhD 8 , 9 , , BA, MA, MSc, MD, FRCPC 1 , 4 , , BMath, MAE, MA, PhD 2 , 3 , , PhD 1 , 2 , 10
      (Reviewer), (Reviewer), (Reviewer)
      JMIR Research Protocols
      JMIR Publications
      digital health technology, care transitions, multimorbidity, pragmatic trial, co-design, hospital, primary care

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          Older adults with multimorbidity and complex care needs (CCN) are among those most likely to experience frequent care transitions between settings, particularly from hospital to home. Transition periods mark vulnerable moments in care for individuals with CCN. Poor communication and incomplete information transfer between clinicians and organizations involved in the transition from hospital to home can impede access to needed support and resources. Establishing digitally supported communication that enables person-centered care and supported self-management may offer significant advantages as we support older adults with CCN transitioning from hospital to home.


          This protocol outlines the plan for the development, implementation, and evaluation of a Digital Bridge co-designed to support person-centered health care transitions for older adults with CCN. The Digital Bridge builds on the foundation of two validated technologies: Care Connector, designed to improve interprofessional communication in hospital, and the electronic Patient-Reported Outcomes (ePRO) tool, designed to support goal-oriented care planning and self-management in primary care settings. This project poses three overarching research questions that focus on adapting the technology to local contexts, evaluating the impact of the Digital Bridge in relation to the quadruple aim, and exploring the potential to scale and spread the technology.


          The study includes two phases: workflow co-design (phase 1), followed by implementation and evaluation (phase 2). Phase 1 will include iterative co-design working groups with patients, caregivers, hospital providers, and primary care providers to develop a transition workflow that will leverage the use of Care Connector and ePRO to support communication through the transition process. Phase 2 will include implementation and evaluation of the Digital Bridge within two hospital systems in Ontario in acute and rehab settings (600 patients: 300 baseline and 300 implementation). The primary outcome measure for this study is the Care Transitions Measure–3 to assess transition quality. An embedded ethnography will be included to capture context and process data to inform the implementation assessment and development of a scale and spread strategy. An Integrated Knowledge Translation approach is taken to inform the study. An advisory group will be established to provide insight and feedback regarding the project design and implementation, leading the development of the project knowledge translation strategy and associated outputs.


          This project is underway and expected to be complete by Spring 2024.


          Given the real-world implementation of Digital Bridge, practice changes in the research sites and variable adherence to the implementation protocols are likely. Capturing and understanding these considerations through a mixed-methods approach will help identify the range of factors that may influence study results. Should a favorable evaluation suggest wide adoption of the proposed intervention, this project could lead to positive impact at patient, clinician, organizational, and health system levels.

          Trial Registration

          ClinicalTrials.gov NCT04287192; https://clinicaltrials.gov/ct2/show/NCT04287192

          International Registered Report Identifier (IRRID)


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          Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science

          Background Many interventions found to be effective in health services research studies fail to translate into meaningful patient care outcomes across multiple contexts. Health services researchers recognize the need to evaluate not only summative outcomes but also formative outcomes to assess the extent to which implementation is effective in a specific setting, prolongs sustainability, and promotes dissemination into other settings. Many implementation theories have been published to help promote effective implementation. However, they overlap considerably in the constructs included in individual theories, and a comparison of theories reveals that each is missing important constructs included in other theories. In addition, terminology and definitions are not consistent across theories. We describe the Consolidated Framework For Implementation Research (CFIR) that offers an overarching typology to promote implementation theory development and verification about what works where and why across multiple contexts. Methods We used a snowball sampling approach to identify published theories that were evaluated to identify constructs based on strength of conceptual or empirical support for influence on implementation, consistency in definitions, alignment with our own findings, and potential for measurement. We combined constructs across published theories that had different labels but were redundant or overlapping in definition, and we parsed apart constructs that conflated underlying concepts. Results The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g., evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12 constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect). We present explicit definitions for each construct. Conclusion The CFIR provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories. It can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings.
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            Case Study Research : Design and Methods

            Providing a complete portal to the world of case study research, the Fourth Edition of Robert K. Yin’s bestselling text Case Study Research offers comprehensive coverage of the design and use of the case study method as a valid research tool. This thoroughly revised text now covers more than 50 case studies (approximately 25% new), gives fresh attention to quantitative analyses, discusses more fully the use of mixed methods research designs, and includes new methodological insights. The book’s coverage of case study research and how it is applied in practice gives readers access to exemplary case studies drawn from a wide variety of academic and applied fields. Key Features of the Fourth Edition Highlights each specific research feature through 44 boxed vignettes that feature previously published case studies Provides methodological insights to show the similarities between case studies and other social science methods Suggests a three-stage approach to help readers define the initial questions they will consider in their own case study research Covers new material on human subjects protection, the role of Institutional Review Boards, and the interplay between obtaining IRB approval and the final development of the case study protocol and conduct of a pilot case Includes an overall graphic of the entire case study research process at the beginning of the book, then highlights the steps in the process through graphics that appear at the outset of all the chapters that follow Offers in-text learning aids including “tips” that pose key questions and answers at the beginning of each chapter, practical exercises, endnotes, and a new cross-referencing table Case Study Research, Fourth Edition is ideal for courses in departments of Education, Business and Management, Nursing and Public Health, Public Administration, Anthropology, Sociology, and Political Science.
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              Design Experiments: Theoretical and Methodological Challenges in Creating Complex Interventions in Classroom Settings

              Ann Brown (1992)

                Author and article information

                JMIR Res Protoc
                JMIR Res Protoc
                JMIR Research Protocols
                JMIR Publications (Toronto, Canada )
                November 2020
                25 November 2020
                : 9
                : 11
                : e20220
                [1 ] Bridgepoint Collaboratory for Research and Innovation Lunenfeld-Tanenbaum Research Institute Sinai Health System Toronto, ON Canada
                [2 ] Institute for Health Policy, Management and Evaluation Dalla Lana School of Public Health University of Toronto Toronto, ON Canada
                [3 ] Institute for Better Health Trillium Health Partners Toronto, ON Canada
                [4 ] Department of Family and Community Medicine University of Toronto Toronto, ON Canada
                [5 ] Clinical, Health System Strategy, Integration and Planning Ontario Health (Central Region) Mississauga Halton Local Health Integration Network Toronto, ON Canada
                [6 ] QoC Health Inc Toronto, ON Canada
                [7 ] Mount Sinai Academic Family Health Team Toronto, ON Canada
                [8 ] Ottawa Methods Centre Ottawa Hospital Research Institute The Ottawa Hospital Ottawa, ON Canada
                [9 ] School of Epidemiology Public Health and Preventative Medicine University of Ottawa Ottawa, ON Canada
                [10 ] March of Dimes Canada Toronto, ON Canada
                Author notes
                Corresponding Author: Carolyn Steele Gray Carolyn.SteeleGray@ 123456sinaihealth.ca
                Author information
                ©Carolyn Steele Gray, Terence Tang, Alana Armas, Mira Backo-Shannon, Sarah Harvey, Kerry Kuluski, Mayura Loganathan, Jason X Nie, John Petrie, Tim Ramsay, Robert Reid, Kednapa Thavorn, Ross Upshur, Walter P Wodchis, Michelle Nelson. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 25.11.2020.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on http://www.researchprotocols.org, as well as this copyright and license information must be included.

                : 13 May 2020
                : 29 June 2020
                : 10 August 2020
                : 13 September 2020

                digital health technology,care transitions,multimorbidity,pragmatic trial,co-design,hospital,primary care


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