Project 460520

As Canadians with life-limiting illnesses in hospital approach the end of life, the focus of their care often shifts to comfort, and they seek to return home. These transitions from hospital to home in palliative care can be emotionally distressing and logistically challenging. When poorly handled, these transitions have negative effects on the physical and psychosocial well-being of patients and family caregivers. Previous interventions have tried, with mixed results, to reduce hospital readmissions after transitioning home by deploying nurse navigators and case managers. None of these hospital-to-home interventions and their outcomes (i.e., hospital readmissions) were developed in partnership with patients and caregivers and none were tested in Canada. Without patient involvement, interventions may not capture the components needed to improve outcomes that most matter to patients. This project aims to co-design an intervention and associated outcomes for the hospital-to-home transition. Co-design engages patients receiving palliative care, their caregivers, and healthcare providers and decisionmakers to develop an intervention and associated outcomes for the hospital-to-home transition. Our approach will ensure all stakeholders are treated as equal collaborators in the design process and decision-making. The process will result in an intervention and selected outcomes. We will conduct an implementation study to test that the intervention is acceptable and feasible. We are working closely with partners at Home and Community Care Support Services Champlain, to implement the intervention as a component of hospital-to-home transitions for patients receiving palliative care. This research has the potential to improve the palliative care experience for thousands of Canadians that want to leave the hospital and transition home for end-of-life care. For patients and their families, to die at home brings peace and comfort, and eases the burden on the healthcare system.