Dr. Mark Toles was recently awarded $75,000 from Lutheran Services in America for the “Connect-Home Collaborative.” The Collaborative is designed to use tools developed by Toles and his team to train patients and caregivers on how to safely make the transition from a skilled nursing facility to home care with few complications.With co-investigator Dr. Jennifer Leeman, Dr. Toles will study the effectiveness of a set of quality improvement strategies for scaling-up the Connect-Home transitional care intervention. The pilot work will be conducted in nursing homes located in Maryland, Michigan, New Jersey and North Carolina.
In the US, nearly two million older adults have episodes of care that include a short stay in a nursing home. The Connect-Home Collaborative aims to refine implementation tools and strategies for integrating transitional care in existing care routines in the nursing homes. The study is significant because it will provide tools and other resources that staff will use to prepare older adults and their family caregivers to manage the patient’s serious illnesses at home.