Optimizing Care Transition Process for Older Colorectal Surgery Patients
For patients and families
In plain language
An automatic summary of structured registry data. It is an orientation aid, not a substitute for the official protocol or a physician assessment.
- What is being studied
- The protocol lists: OSCAR-S Care Transition Model.
- Who it may be relevant to
- Registry conditions: Colorectal Surgery, Care Transition, Older Adults (65 Years and Older). Basic parameters: from 65 years · All.
- What needs checking
- Age, condition and sex are only basic indicators. Prior treatment, laboratory values and other mandatory requirements appear in the eligibility criteria below.
- Where it takes place
- United States
- Next step
- Save the trial, show it to the treating physician, and confirm current recruitment with the study center. Costs, documents and travel →
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Official title
Optimization of Care and Recovery in Older Colorectal Surgery Patients: A Hybrid Effectiveness-Implementation Pilot Study Protocol
Overview
The goal of this study to test if a care transition intervention designed for older colorectal surgery patients would improve outcomes after discharge. It will assess the feasibility of the intervention.
Detailed description
The period following discharge poses particularly high risks for older colorectal surgery patients. Nearly a quarter of these patients are readmitted within a month of discharge due to a variety of issues including medication errors, surgical complications, imbalance in fluid or nutrition, or worsening of pre-existing chronic diseases.Recognizing the complex interplay of these factors, it isa more comprehensive approach is imperative to improve post- operative patient care. Geriatrics co-management programs incorporate interdisciplinary patient management approaches and geriatric principles to improve outcomes in older surgical patients.The OSCAR program is an integrated care model developed by geriatricians in collaboration with colorectal surgeons that combines geriatrics co-management with postoperative surgical care for older colorectal surgery patients. The care transition intervention (CTI) is a well-established care transition model that focuses on four domains at discharge: 1) medication self-management, 2) the personal health record, 3) timely primary care/specialty care follow-up, and 4) knowledge of red flags that indicate a worsening in condition. CTI involves interactions with a trained transition coach, both in-person visits and phone calls over four weeks. In this study, the goal is to bridge the gap between inpatient and post-discharge phases and mitigate the risk of hospital readmissions through adaptation and combination of the core components of a geriatric surgery core co-management (OSCAR) program with the core components of a care transition (CTI) program by applying an implementation research approach. By customizing OSCAR co-management model with the CTI intervention model, the investigators will leverage their strengths and, efficiently address the unique requirements of both patients and the healthcare environment. The investigators will conduct a pilot feasibility hybrid type I implementation effectiveness trial of OSCAR-S.
Interventions
- Behavioral OSCAR-S Care Transition Model
Patients and families in the intervention arm will receive touch points from the surgery nurse coach to support their care transition from hospital to home after surgery.
Primary outcome measures
- Postdischarge 30-day readmission or death [Time frame: 30 days]
Secondary outcome measures (5)
- Reach [Time frame: 12 months]
- Fidelity [Time frame: 12 months]
- Adoption [Time frame: 12 months]
- Effectiveness - Patient Satisfaction [Time frame: 30 days]
- Effectiveness - Postoperative Complications [Time frame: 30 days]
Eligibility criteria
Inclusion criteria
- Adult patients (>65 years old)
- Scheduled to undergo an elective colorectal surgery procedure
- Ability to provide informed consent
Exclusion criteria
- Emergent, non-elective colorectal procedures
- Non-English Speaking
Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.
Healthy volunteers: No
Study design
- Allocation
- N/A
- Model
- Single group
- Masking
- Open label
- Primary purpose
- Supportive care
Study locations
United States · 1 center
- 81 Highland Ave — Salem
Publications
- Yildiz F, Bartels SJ, Cauley C, Vrees M, Crabtree BF, Marcantonio ER, Ritchie CS, Hwabejire JO, Ricciardi R, Deiner SG, Cizginer S. Optimization of care and recovery in older colorectal cancer surgery patients: a hybrid effectiveness-implementation pilot study protocol. Pilot Feasibility Stud. 2026 Mar 21;12(1):58. doi: 10.1186/s40814-026-01796-9. PMID 41865059
Identifiers
NCT: NCT06752031 · K76AG078620-02