Development and Feasibility of a Function-focused Transitional Care Intervention to Support Functional Recovery in Older Veterans

About This Grant

Significance to VA: This project addresses the need to support older Veterans’ functional recovery during transitions from hospital to home. Functional decline after hospital discharge results from a complex interplay between pre-existing health conditions, physiological stressors, and reduced mobility throughout hospitalization. Veterans are particularly vulnerable to functional decline after discharge due to their high burden of physical and psychological conditions. Transitions from hospital to home serve as important junctures to address functional decline, but Veterans are often discharged without a comprehensive functional evaluation, putting them at increased risk for negative post-hospital outcomes. The Coordinated Transitional Care (CTraC) program is a nurse-led transitional care intervention developed to improve Veterans’ transitions home after hospitalization. CTraC has demonstrated significant benefits for Veterans, including reduced readmissions, improved patient safety, and increased engagement in care. Yet, the existing CTraC protocol misses a critical opportunity to include assessment, intervention, and care coordination supportive of Veterans’ functional recovery. Innovation and Impact: This project aims to develop and test a novel, function-focused protocol for VA’s CTraC program. The goal of this work is to improve functional outcomes for Veterans, empowering them to achieve greater independence and quality of life. This work is responsive to VA’s strategic goals and the mission of VA RR&D which seeks strategies to mitigate the impact of chronic conditions for aging Veterans. This work is also well-aligned with VA priorities such as integrating Whole Health care practices and becoming the largest integrated Age-friendly Health System via delivery of care aligned with the 4Ms: mobility, mentation, medication, what matters. Specific Aims: Aim 1: Develop and refine CTraC-FIT (Functional Independence aT home) for Veterans at risk of functional decline transitioning from hospital to home. Aim 2: Examine the feasibility and acceptability of CTraC-FIT in a pilot randomized controlled trial. Methodology: This project uses a mixed-methods approach with two phases. Phase 1 focuses on intervention development and refinement. Qualitative interviews with VA clinicians (n=15) will inform development of the CTraC-FIT protocol. A small-scale nonrandomized pilot (n=5 Veterans) will assess initial intervention feasibility and acceptability. Qualitative feedback from Veterans will guide refinement of the intervention protocol and study procedures. Phase 2 focuses on pilot testing. A pilot randomized controlled trial will compare CTraC-FIT to enhanced usual care in 40 older Veterans at risk of functional decline (1:1 comparison; n=20 per group). Feasibility and acceptability of the intervention protocol will be measured via surveys and qualitative interviews with Veterans, and surveys with clinicians (n~20). Exploratory outcomes of quality of life and physical, cognitive, and social function will be measured via self-reported and performance-based quantitative assessments at baseline, post-intervention, and 3-months post-intervention. Path to Translation/Implementation: The results of this CDA-2 will lay the groundwork for a future RR&D Merit application to support a multi-site Stage II randomized controlled trial of the CTraC-FIT intervention. By leveraging the existing successful CTraC program and infrastructure, the CTraC-FIT intervention has strong potential for widespread implementation across the VA healthcare system. This work is aligned with key VA priorities, poised to enhance transitional care delivery, and designed to support Veterans’ functional recovery after hospital discharge to home.