Evidence map›Paper›PMID 40722056›Full record

ArticleBMC geriatrics2025

Optimising older People's Transition from acute care Into residential aged care through Multidisciplinary Assessment and Liaison (OPTIMAL): protocol for a stepped wedge cluster randomised controlled trial with embedded process evaluation.

Rangika L Fernando, Jonathan Karnon, Maria Crotty, Maria C Inacio, Madeleine Baillie, Ishita Batta, Alice Bourke, John Forward, Chloe Furst, Robert Jorissen and 4 more

Abstract readClinical Trial Protocol
In one paragraph

Article in BMC geriatrics, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 3 papers.

0numbers the graph read from it
0cells of the map it votes in
3citing papers in PubMed
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

3 citing papers in PubMed.

  1. Rethinking Postdischarge Intervention Evaluation.Journal of medical Internet research · 2026
    Article
  2. Article
  3. Review
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

14 authors.

Rangika L FernandoFlinders University, College of Medicine and Public Health, Flinders Health and Medical Research Institute, Adelaide, South Australia, Australia. rangikalakshini.fernando@flinders.edu.au.ORCID http://orcid.org/0000-0002-2840-204X
Jonathan KarnonFlinders University, College of Medicine and Public Health, Flinders Health and Medical Research Institute, Adelaide, South Australia, Australia.ORCID http://orcid.org/0000-0003-3220-2099
Maria CrottyFlinders University, College of Medicine and Public Health, Flinders Health and Medical Research Institute, Adelaide, South Australia, Australia.ORCID http://orcid.org/0000-0002-2996-5135
Maria C InacioRegistry of Senior Australians (ROSA) Research Centre, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia.ORCID http://orcid.org/0000-0001-8261-2665
Madeleine BaillieCentral Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia.
Ishita BattaCentral Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia.
Alice BourkeNorthern Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia.
John ForwardNorthern Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia.
Chloe FurstCentral Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia.
Robert JorissenRegistry of Senior Australians (ROSA) Research Centre, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia.ORCID http://orcid.org/0000-0001-9634-2803
Georgina NeillCommission on Excellence and Innovation in Health, Government of South Australia, Adelaide, South Australia, Australia.
Georgina SzaboCommission on Excellence and Innovation in Health, Government of South Australia, Adelaide, South Australia, Australia.ORCID http://orcid.org/0009-0003-7866-2434
Craig WhiteheadFlinders University, College of Medicine and Public Health, Flinders Health and Medical Research Institute, Adelaide, South Australia, Australia.
Gillian HarveyFlinders University, College of Nursing and Health Sciences, Caring Futures Institute, Adelaide, South Australia, Australia.ORCID http://orcid.org/0000-0003-0937-7819

Funding

Australian Government Medical Research Future Fund (MRFF) 2018250
6 · The paper itself

Abstract

backgroundCare transitions by older adults discharged from hospital require good coordination and communication to prevent adverse events and potentially preventable readmissions. Implementation of multicomponent interventions tailored to patient risk can improve the quality of transitions and reduce potentially preventable readmissions. Several such multicomponent interventions exist, but evidence of their transferability and effectiveness for individuals discharged to residential aged care (RAC) and within the Australian context is required.

methodsThe Optimising older People’s Transition from acute care Into residential aged care through Multidisciplinary Assessment and Liaison (OPTIMAL) trial is a multi-site hybrid type II stepped wedge cluster randomised controlled trial with embedded process and economic evaluations. The study aims to collaboratively implement a bundle of evidence-based interventions with clinicians, administrators, and researchers to provide systematic support for first time discharges to RAC, and to determine the clinical effectiveness, cost effectiveness, and feasibility, acceptability, adoption and fidelity of implementation. The study design is informed by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, which will guide implementation and process evaluation. The OPTIMAL intervention will be implemented sequentially over 14 months across selected hospital wards in three local health networks (LHNs) in South Australia. Implementation will occur in a random order, with one LHN transitioning to the intervention phase every four months. It will include all patients 65 years and older discharged from the selected wards to RAC for the first time. Eligible participants will be stratified based on their risk of readmission and receive a customized bundle of interventions relative to their level of risk. Each LHN team will tailor an intervention bundle informed by existing evidence and a registered nurse will facilitate its implementation. The primary outcome is the proportion of participants with emergency department presentations and/or readmissions and/or death within 30 and 90 days of discharge. A total of 1545 participants are expected to be enrolled, commencing 1st September 2024. DISCUSSION: This study will provide evidence on the transferability and effectiveness of implementing multicomponent and risk stratified enhanced care bundles in the Australian context, and can inform improvement activities for care transitions by older adults.

trial registrationAustralia New Zealand Clinical Trial Registry ACTRN12624001008516, registered 20th August 2024.

Indexed as

Homes for the AgedPatient DischargePatient TransferAgedAustraliaHumansMulticenter Studies as TopicRandomized Controlled Trials as TopicCare transitionsHospital dischargeImplementationNursing homesOlder adultsPatient readmissionResidential aged careStepped wedge cluster randomised trial

Identifiers

PMID40722056
PMCPMC12302694

What OpenQuestion holds

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Registered trials

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.