I-TRANSFER Improving TRansitions ANd outcomeS oF sEpsis suRvivors

Acute care hospitals discharge over 1.5 million sepsis survivors annually. Sepsis survivors are twice as likely
as non-sepsis patients to be readmitted within 30 days, with 32% of those readmissions occurring within 7
days. Annually, over one third of sepsis survivors transition to skilled home health care (HHC) after their
hospitalization where nurses monitor for reinfection, support uninterrupted medication management, and work
with patients, caregivers, other providers to support continued recovery. This proposed competing renewal is
based on HHC best practice evidence generated by our previous study (RO1-NR016014) showing the value of
early visits by registered nurses and early outpatient provider follow-up. We found that 30-day rehospitalization
rates were 7 percentage points lower (a 41% relative reduction) when sepsis survivors received a HHC nursing
visit within 2 days of hospital discharge, at least 1 more visit the first week, and an outpatient provider follow-up
visit by 7 days compared to those without timely follow-up. However, nationwide, only 28% of sepsis survivors
who transitioned to HHC received this early visit protocol because several barriers to achieving this protocol
exist. To advance the science, the proposed study will test the effectiveness of this practice in the real
world and study the implementation with a pragmatic, Type 1 hybrid, stepped wedge randomized trial
in partnership with dyads of acute and HHC stakeholders. Aim 1: Test the effectiveness of the I-
TRANSFER intervention compared to usual care on 30-day rehospitalization and emergency department use
among sepsis survivors receiving home health care. The stepped wedge protocol will involve a baseline period
with no intervention, and two steps where randomized dyads provide the intervention. In addition to the usual
care/control periods from the dyad sites, additional survivors from national data will provide a much larger
sample of control observations, weighted to produce covariate balance. The hypotheses will be tested using
generalized mixed models with covariates guided by the Anderson Behavioral Model of Health Services. In aim
2 we will: Produce insights and generalizable knowledge regarding the context, processes, strategies, and
determinants of I-TRANSFER implementation. The implementation aim is guided by the Consolidated
Framework for Implementation Research. As the largest HHC study of its kind and the first to transform this
type of care through implementation science, the proposed study has the potential to produce new knowledge
about the process of transition to and care in home health. If effective, the impact of this intervention during this
common transition process could be widespread, improving the outcomes for a growing, vulnerable population
of sepsis survivors. An Advisory Group of national experts will assist with widespread dissemination of the
study results.

Grant Number: 5R01NR016014-07
NIH Institute/Center: NIH
Principal Investigator: Kathryn Bowles