Project Connect

Background: The Connecting Neighborhood Elderly with Community-based Teams (ConNECT) pilot is a collaboration between Silberman Aging, Mt. Sinai Hospital Emergency Department and 4 community-based agencies. ConNECT was designed to evaluate the feasibility of implementing a larger RCT of this community based model to bridge the gap between current short-term medical transitional models of care and long term supportive community-based services. Although there is evidence that effective care transitions can reduce emergency department (ED) visits and unnecessary hospital admissions, the current brief hospital-based medical care transition models do not adequately meet the longer-term needs of high risk older patients with complex social, behavioral, and/or mental health issues. Key informant interviews, focus groups with service providers and preliminary data from the Geriatric Emergency Department Innovations-Workforce, Informatics, and Systems Enhancement (GEDI WISE) program suggested approximately 20% of older adults discharged from the ED required a more sustained time-sensitive engagement than that offered. ConNECT integrates key elements of evidence-based transitional care interventions with Critical Time Intervention, a 3-Phase intervention recognizing, as the name suggests, critical moments for intervention and subsequently decreasing in intensity over a period of 4-6 months.

Implementation/Methods: A risk assessment was used to enroll participants in either the High or Low Risk arm of the study. The High Risk patients (N=20) were contacted by the MSW within 24 hours of discharge with the initial home visit completed within 72 hours. Participants in the Low intensity intervention (N=20) received 1-2 home visits from a volunteer from a local medical mentoring program to accompany the participant to a participating senior center. In addition to process data, service utilization and hospital admissions, the feasibility of collecting data on Global Health, Physical Function, Emotional Support and Isolation was evaluated.  

Findings: Process data identified barriers such as efficient transfer of patient information, scheduling follow-up visits and the transfer of coordination responsibility from the MSW to BS/BSW community navigator must be addressed prior to implementing the future RCT. The MSW reported it required 4 home visits to complete the assessment and accompany the participant to follow-up appointments with their PCP, prior to transitioning the case to the community navigator. The navigators made approximately 6 follow-up visits supplemented with frequent telephonic contacts. Findings from the Low intensity arm of the study suggest that while the older adults agreed to home visits by the volunteers, the majority rejected offers to accompany them to the senior center.

Implications: Findings of this pilot support the importance of using a team approach led by a MSW during the immediate transition from hospital to home. The community navigator achieved the vast majority of the initial goals of the care plan. Further study is required to make meaning of the unexpected high rate of refusal in the Low Intensity arm of the study. This session will conclude with an overview of the strategies that were used to engage our community-based partners in developing the intervention, training and implementation of the ConNECT Intervention and modifications for the subsequent RCT.