Improving Care and Recovery for Older Adults After Elective Colorectal Surgery A Pilot Study of a Nurse-Led Care Transition Support Program

What this Trial Is About

This research aims to improve outcomes for older patients undergoing colorectal surgery by testing a care transition intervention after hospital discharge. The study focuses on reducing hospital readmissions within 30 days, which often happen due to medication errors, surgical complications, or worsening chronic conditions. It evaluates a combined approach using the OSCAR co-management model and a care transition intervention CTI tailored for older adults. The intervention involves a surgery nurse coach providing support to patients and their families as they transition from hospital to home. The CTI includes in-person visits and phone calls over four weeks, addressing medication management, personal health records, timely follow-up care, and recognizing warning signs of health decline. This hybrid study combines geriatric surgical care with transition coaching to meet the unique needs of older colorectal surgery patients. Participants will have regular interactions with the nurse coach and complete assessments related to readmission or death within 30 days after discharge. The study also measures patient satisfaction, postoperative complications, and implementation factors such as reach, fidelity, and adoption over 12 months. The total participation involves monitoring the transition process and outcomes to assess the feasibility and effectiveness of the OSCAR-S care transition model.

Optimizing Care Transition Process for Older Colorectal Surgery Patients