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.

BACKGROUND

Care 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.

METHODS

The 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 REGISTRATION

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

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1186/s12877-025-06187-y.