Hospital-to-Home: logic model and theory of change exercise to identify outcomes arising from integrated health and social care.
Bibliographic record
Abstract
Introduction: Although Canada boasts universal access to hospital-based services, bed capacity has been a challenge with long wait times for acute admissions to a hospital bed from the Emergency Department. The use of hospital beds by ‘alternate level of care’ (ALC) patients is a critical concern. These ALC patients exist because of a lack of an appropriate level of care in the community. Integrated health and social care (IHSC) can limit avoidable acute care utilization including in-patient stays in hospitals. CHATS--Community & Home Assistance to Seniors is a community-based agency that provides transportation, meals, in-home services, caregiver relief, education and support, community wellness, and 24/7 assisted living among other services, with the aim of supporting ageing in place. CHATS has partnered with several local hospitals and homecare providers to create a number of hospital-to-home programs (HTH) that provide seamless and coordinated care from hospital to home for older adults enabling safe and effective transitions. Hospital-based data has shown that ALC days and inpatient and ED hospital readmissions declined following implementation of HTH programs. Although hospital-based data is available, community-based health and social care outcome-based metrics have not been developed nor collected. Despite limited qualitative data showing high levels of client and caregiver satisfaction with its HTH services, the lack of outcome-based data makes it difficult for CHATS to articulate the benefits of the HTH programs from a community-based perspective that reflects both health and social care outcomes with the aim of informing policy and programming decisions in the future, including program scale and spread. Methodology: A logic model (LM) and theory of change (ToC) exercise was undertaken by a broad representation of CHATS staff at all levels of the organization to identify the theory of change for the HTH programs and critical activity-based and outcome-based metrics to support future measurement and evaluation work. The development of these models clarified the fundamental program theory behind community agency contributions to the HTH programs that enable their success. Results: The theory of change noted that the HTH program was able to achieve hospital to home transition success because it facilitates older adult clients to achieve greater self-determination that can support more independent living. The HTH program’s components, case management, personal support, transportation, training, counselling, and assessments ensure that the personal goals of clients and their caregivers are identified and addressed. Feelings of empowerment, improved mental health, health and social care navigation literacy, and reduced acute care readmissions are some of the outcomes perceived as being attributable to the HTH programs. These outcomes, in turn, allow for greater overall health and wellbeing, and sense of independence among older adult clients and their caregivers. Ultimately, the HTH programs contribute towards greater systems efficiency and enhanced quality of life for clients and their family/caregivers. Next steps: The results of the LM and ToC exercises have enabled CHATS to identify critical input, activity and outcome measures for the HTH programs that reflect the contributions of CHATS, and a towards a future summative evaluation of the HTH programs.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.010 | 0.015 |
| Meta-epidemiology (narrow) | 0.001 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.002 |
| Bibliometrics | 0.005 | 0.003 |
| Science and technology studies | 0.002 | 0.006 |
| Scholarly communication | 0.005 | 0.007 |
| Open science | 0.003 | 0.003 |
| Research integrity | 0.002 | 0.002 |
| Insufficient payload (model declined to judge) | 0.010 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".