Pilot Process Evaluation of the Supporting Older Adults at Risk Model: A RE-AIM Approach.

Abstract: Despite evidence supporting transitional care models, hospitals report challenges implementing and sustaining them. The Discharge to Assess (D2A) Model is an innovative solution to this problem but required translation from a national health system context to an U.S.-based context. We translated the central tenets of the D2A model to establish the Supporting Older Adults at Risk (SOAR) Model, which unfolds in three phases: Prepare, Transition, and Support. The purpose of this project was to conduct a process evaluation of the SOAR Model in practice using the RE-AIM Framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance). Forty patients completed all SOAR Model components for a Reach of 21%. Patients averaged 80 years of age, 53% were female, and 64% Black/AA. SOAR significantly improved discharge before noon, time to first home visit, and use of the in-house pharmacy. SOAR also improved length of hospital stay, emergency department visits, and readmissions. Twenty-one of the 26 Implementation measures unfolded with 75% or greater fidelity. Sixteen of the 24 Adoption measures unfolded with 75% or greater fidelity. COVID-19 limited Maintenance. Given the model unfolds across settings over time, requiring adoption from interprofessional team members, patients, and families, future work should focus on improving reach and adoption.