LTC-to-hospital Transfer Decision-makingSTEPNCT07153341
Evaluation of the STEP Intervention for Long-Term Care Residents Facing Hospital Transfer Decisions
A study testing STEP Decision Support Toolkit in people with LTC-to-hospital Transfer Decision-making, run by Bruyère Health Research Institute. at 2 sites in Canada.
Trial summary
This trial will evaluate whether the Supporting Transitions and Empowering Preferences (STEP) toolkit can improve decision-making about hospital transfers in long-term care residents and their substitute decision-makers and enhance decision self-efficacy in nursing staff. Read more about this study
- Who is it for?
- Ages 55 years and older
- Conditions the study is for
- LTC-to-hospital Transfer Decision-making
- What is being tested?
- STEP Decision Support Toolkit
- Type of treatment
- Lifestyle or therapy programme
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 200 participants
- Where
- 2 sitesCanada
- Study dates
- 1 Oct 2025to 1 Sep 2027
- Phase
- Interventional
- Are there results?
- Not yet: the study is under way
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 55 years and older
- All sexes
- No healthy volunteers
- Adult, Older adult
Who may be able to join
- Residents-care partner dyads:
- Must be residents of either Perley Health or Bruyère Health Saint-Louis LTC home.
- Residents must be 55 years of age or older.
- Must be able to communicate in French or English.
- Both members of the dyad will be included where applicable. For dyads in which residents do not have the capacity to participate, inclusion will occur through the involvement of their substitute decision-maker (e.g., power of attorney for personal care).
- LTC staff:
Show all 10Show fewer
- Must be a nurse, nurse practitioner, social service worker or physician actively involved in care planning, annual conferences, or managing acute health events at Perley Health or Bruyère Health.
- Must have been employed at the LTC home for at least 6 months to ensure familiarity with the care environment and residents.
- Must play a role in facilitating discussions, providing clinical input (where applicable), or guiding decision-making processes related to hospital transitions or acute care management.
- Must be able to communicate in French or English.
Who cannot join
None listed.
Trial locations and contacts
2 sites in 1 country. Contact the study team or a site near you to ask about taking part.
Canada2 sites, 2 recruiting
- Recruiting
Bruyère Health Saint-Louis Long-Term Care
Ottawa, Ontario, K1C 2Z6
- Recruiting
Perley Health
Ottawa, Ontario, K1G 4B2
About this study
Official title: A Pre-Post Trial Evaluating the Supporting Transitions and Empowering Preferences (STEP) Decision Support Intervention for Long-Term Care Residents Facing Hospital Transfer Decisions During Acute Health Crises
This trial will evaluate whether the Supporting Transitions and Empowering Preferences (STEP) toolkit can improve decision-making about hospital transfers in long-term care residents and their substitute decision-makers and enhance decision self-efficacy in nursing staff.
The trial will answer the questions:
Read more
- Does the STEP tool reduce decisional conflict in residents and care partners at the time of transfer decisions?
- Does it improve nurse self-efficacy related to hospital transfer decisions?
Participants will:
- Use the STEP tool during key moments of care planning (admission, care conferences, and acute events)
- Complete a short survey measuring their decisional conflict
- Be supported by trained nurses who use STEP to guide hospital transfer discussions
Researchers will compare data collected before and after the STEP tool is implemented at two long-term care homes to see if it improves shared decision-making related to hospital transfers by reducing decisional conflict.
Read the detailed description
Background and Rationale: Transitions from long-term care (LTC) to hospital are complex and can offer both benefits and challenges to residents and care partners. While LTC-to-hospital transitions can improve health outcomes, particularly during acute deterioration, evidence also indicates that these transitions may disrupt continuity of care, increase stress, and misalign resident needs with hospital protocols. Nearly fifty percent of LTC residents in Canada experience hospital transitions annually, with approximately forty percent considered avoidable. Risks include non-evidence-based care, safety concerns, unnecessary interventions, and increased mortality rates. Transition decisions are influenced by residents' health status, medico-legal concerns, staff workload, and care partners' confidence in LTC care. These decisions are often reactive and shaped by unequal power dynamics rather than proactive, collaborative planning.
Given these challenges, and limitations in current monitoring systems such as the Minimum Data Set assessments, there is a critical need for a decision aid that supports informed, resident-centered planning. The Supporting Transitions and Empowering Preferences (STEP) tool was developed through interviews, co-design sessions, document analysis, and stakeholder engagement.
Objectives Primary Objective: Evaluate the impact of STEP on decisional conflict among residents and care partners.
Secondary Objective: Examine the effect of STEP on nurses' self-efficacy as decision coaches at the time of transition decisions.
Trial Design and Study Setting: A pre-post evaluation will be conducted at two LTC sites (Perley Health and Bruyère Health Saint-Louis LTC) to assess STEP's ability to support resident-care partner dyads in making hospital transition decisions. STEP will be implemented simultaneously at both sites.
Study Overview: Data will be collected for six months pre-intervention or until the target sample size is reached (n=100), followed by the intervention period. Nurses, nurse practitioners, social service workers, and physicians will receive STEP training, with designated champions supporting implementation. Data will be collected at three points: after intake/admission meetings, after care conferences, and after acute events in which a transfer is considered.
Vanguard Phase Implementation: An initial vanguard phase involving approximately ten residents over four to six weeks will test feasibility, refine recruitment, and assess staff comfort before broader rollout.
Description of the Intervention (Overview): The STEP intervention includes three resources: (1) an educational booklet about transition decisions, (2) a structured decision aid, and (3) a phone script for nursing staff calling substitute decision-makers at the time of a transfer decision. Staff will be trained on the use of these resources with sessions scheduled to accommodate different shifts. STEP will be introduced at admission (educational booklet), reviewed at post-admission or annual care conferences (booklet + decision aid), and used during acute health events (decision aid + phone script) to guide structured conversations about hospital transfer decisions.
Monitoring Fidelity: Implementation fidelity will be monitored through nurse logs, informal discussions, and champion reports, assessing feasibility, acceptability, and adherence.
Data Collection Procedures (Overview): Dyads will be identified through care reports and hospital transfer notifications, with eligibility verified prior to consent. Data will be collected using secure REDCap software. For nurses, care conference and physician call notes will be reviewed to identify eligible cases. Surveys and brief interviews will assess experiences, confidence, and barriers to STEP use.
Analysis: Analyses will follow an intention-to-treat approach using Generalized Estimating Equations for repeated measures. Differences between groups will be examined using t-tests or chi-squared tests. Missing data will be minimized through follow-up; cases lost after three unsuccessful contact attempts will be excluded from analysis.
- Conditions
- LTC-to-hospital Transfer Decision-making
- Being tested
- STEP Decision Support Toolkit
- Keywords
- long-term care, hospital transfers, acute health events, decision-making in older adults, resident-centred care, substitute decision-makers, frailty, cognitive impairment, shared decision-making, avoidable hospitalizations, transitional care, decision aid, health decision support, decision coaching, pre-post intervention study, healthcare quality improvement, decisional conflict, decisional regret
- Medical subject headings
- Frailty, Cognitive Dysfunction
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
STEP Decision Support ToolkitBehavioural
The STEP toolkit includes (1) an educational booklet provided upon admission and annually, (2) condition-specific decision aids addressing common clinical scenarios, and (3) structured phone scripts for staff. STEP empowers residents and care partners to actively engage in decision-making, promotes care aligned with personal values, and supports staff in facilitating advance care planning to reduce unnecessary or complex transitions.
| Study group | Role | What they receive |
|---|---|---|
| STEP Intervention | Experimental | Participants (resident-care partner dyads) in this arm will receive the STEP intervention. STEP is a decision aid designed to support shared decision-making about whether to transfer to hospital or remain in LTC during acute health events. It includes an educational booklet, a structured decision aid, and a staff phone script used at three points in the resident's care journey: (1) upon LTC admission, (2) during annual care conferences, and (3) at the time of an acute medical event. LTC nurses will receive training to deliver the STEP tool and support residents and care partners in making informed, values-based transition decisions. Receives: Behavioral: STEP Decision Support Toolkit |
What is being measured
The primary outcome is the main question the study is designed to answer.
Decisional Conflict
Measured using the Decisional Conflict Scale (16 items; each rated on a 5-point scale; standardized total score 0-100, with higher scores indicating greater decisional conflict and worse decision-making outcomes).
Measured: Administered by Research Assistant 1-6 weeks after a transition decision.
Secondary outcomes (3)
Decision Self-Efficacy
Measured using the Decision Self-Efficacy Scale (11 items; each rated 0-4, standardized to a 0-100 score, with higher scores indicating greater decision self-efficacy and better outcomes).
Measured: Administered by Research Assistant 1-6 weeks after a transition decision and periodically thereafter.
Transition Rate
Measured as the rate of hospital transitions during the pre- and post-intervention periods, including: (1) total number of transitions documented in electronic medical records; (2) avoidable transitions, defined as transitions for conditions that could have been managed in the LTC home (e.g., non-critical infections, falls without significant injury); and (3) repeat transitions, defined as multiple transitions experienced by the same resident within a 6-month period.
Measured: Measured continuously during the 6 months pre-intervention and 6 months post-intervention periods.
Resident Health Outcomes Post-Transition
Measured as the rate of rehospitalizations within 30 days of discharge among residents who experienced a hospital transition. This outcome will be assessed using electronic medical records, contingent on resident consent and feasibility of participant identification. Higher rates indicate worse health outcomes.
Measured: Measured continuously during the 6 months pre-intervention and 6 months post-intervention periods.
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted3 Sep 2025
- Study start1 Oct 2025
- Primary completion4 Mar 2026 (estimated)
- Study completion1 Sep 2027 (estimated)
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (8)Papers the sponsor has linked to this study.
- Other trials for LTC-to-hospital Transfer Decision-makingStudies of the same condition, open and under way.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase N/A
- Primary purpose
- Health services research
- Allocation
- Not applicable
- Intervention model
- Single group
- Model description
- This trial uses a pre-post evaluation design at two LTC sites. All participants receive the same intervention (the STEP tool), with no comparison group or randomization to different arms. Outcomes are compared before and after the intervention within the same group (resident-care partner dyads and nurses).
- Masking
- None (open label)
- Enrolment
- 200 participants (estimated)
Sponsor and investigators
- Lead sponsor
- Bruyère Health Research Institute.
- Sponsor type
- University, hospital or other
- Responsible party
- Sponsor
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT07153341
- Sponsor's protocol ID
- M16-25-017
- Other IDs
- 478736
- Acronym
- STEP
- Status last verified
- Jan 2026
- First submitted
- 19 Aug 2025
- Last updated
- 6 Feb 2026
- Results posted
- No
- Data monitoring committee
- No
- FDA-regulated drug
- No
- FDA-regulated device
- No
- Individual data sharing
- No: Given the small sample size, the sensitive nature of data collected in long-term care settings, and the potential risk of participant re-identification, we do not plan to share IPD publicly. However, IPD may be shared on a case-by-case basis in response to reasonable, ethically approved requests. Aggregate results will be disseminated through publications and presentations.
Publications
Tappen RM, Elkins D, Worch S, Weglinski M. Modes of Decision Making Used by Nursing Home Residents and Their Families When Confronted With Potential Hospital Readmission. Res Gerontol Nurs. 2016 Nov 1;9(6):288-299. doi: 10.3928/19404921-20160920-01. Epub 2016 Sep 27.
PubMed 27665753Marincowitz C, Preston L, Cantrell A, Tonkins M, Sabir L, Mason S. What influences decisions to transfer older care-home residents to the emergency department? A synthesis of qualitative reviews. Age Ageing. 2022 Nov 2;51(11):afac257. doi: 10.1093/ageing/afac257.
PubMed 36413591Gruneir A, Bronskill SE, Newman A, Bell CM, Gozdyra P, Anderson GM, Rochon PA. Variation in Emergency Department Transfer Rates from Nursing Homes in Ontario, Canada. Healthc Policy. 2016 Nov;12(2):76-88.
PubMed 28032826Gruneir A, Anderson GM, Rochon PA, Bronskill S. Transitions in long-term care and potential implications for quality reporting in Ontario, Canada. J Am Med Dir Assoc. 2010 Nov;11(9):629-35. doi: 10.1016/j.jamda.2010.07.007.
PubMed 21029997Cummings GG, McLane P, Reid RC, Tate K, Cooper SL, Rowe BH, Estabrooks CA, Cummings GE, Abel SL, Lee JS, Robinson CA, Wagg A. Fractured Care: A Window Into Emergency Transitions in Care for LTC Residents With Complex Health Needs. J Aging Health. 2020 Mar;32(3-4):119-133. doi: 10.1177/0898264318808908. Epub 2018 Nov 15.
PubMed 30442040Abraham S, Menec V. Transitions Between Care Settings at the End of Life Among Older Homecare Recipients: A Population-Based Study. Gerontol Geriatr Med. 2016 Dec 15;2:2333721416684400. doi: 10.1177/2333721416684400. eCollection 2016 Jan-Dec.
PubMed 28680944Menard A, Singh Y, Adams M, Bai JQA, Kobewka D, MacLeod KK. "We Didn't Ask to Be Sick:" Equipping Residents and Care Partners for Transitions From Long-Term Care to Hospital. J Am Geriatr Soc. 2025 Aug;73(8):2410-2421. doi: 10.1111/jgs.19535. Epub 2025 May 30.
PubMed 40444661Menard A, Konikoff L, Adams M, Singh Y, Scott MM, Yin CY, Kimura M, Kobewka D, Fung C, Isenberg SR, Kaasalainen S, Kierulf J, Molnar F, Shamon S, Wilson K, Kehoe MacLeod K; Ottawa Hospital Research Institute and Bruyere Health Research Institute. Supporting resident-centred decision-making about transitions from long-term care homes to hospital: a qualitative study protocol. BMJ Open. 2024 Nov 29;14(11):e086748. doi: 10.1136/bmjopen-2024-086748.
PubMed 39615892
Study at a glance
From the registry record, last updated by the sponsor on 6 Feb 2026. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- A Pre-Post Trial Evaluating the Supporting Transitions and Empowering Preferences (STEP) Decision Support Intervention for Long-Term Care Residents Facing Hospital Transfer Decisions During Acute Health Crises
- ClinicalTrials.gov ID
- NCT07153341
- Acronym / sponsor ID
- STEP / M16-25-017
- Conditions
- LTC-to-hospital Transfer Decision-making
- Keywords
- long-term care, hospital transfers, acute health events, decision-making in older adults, resident-centred care, substitute decision-makers, frailty, cognitive impairment
- Study type
- Interventional
- Recruitment status
- Recruiting
- Enrolment
- 200 participants (estimated)
- Lead sponsor
- Bruyère Health Research Institute.University, hospital or other
- Study start
- 1 Oct 2025 (actual)
- Primary completion
- 4 Mar 2026 (estimated)
- Study completion
- 1 Sep 2027 (estimated)
- First posted
- 3 Sep 2025 (actual)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
This trial will evaluate whether the Supporting Transitions and Empowering Preferences (STEP) toolkit can improve decision-making about hospital transfers in long-term care residents and their substitute decision-makers and enhance decision self-efficacy in nursing staff.
The trial will answer the questions:
- Does the STEP tool reduce decisional conflict in residents and care partners at the time of transfer decisions?
- Does it improve nurse self-efficacy related to hospital transfer decisions?
Participants will:
- Use the STEP tool during key moments of care planning (admission, care conferences, and acute events)
- Complete a short survey measuring their decisional conflict
- Be supported by trained nurses who use STEP to guide hospital transfer discussions
Researchers will compare data collected before and after the STEP tool is implemented at two long-term care homes to see if it improves shared decision-making related to hospital transfers by reducing decisional conflict.
Detailed description
Background and Rationale: Transitions from long-term care (LTC) to hospital are complex and can offer both benefits and challenges to residents and care partners. While LTC-to-hospital transitions can improve health outcomes, particularly during acute deterioration, evidence also indicates that these transitions may disrupt continuity of care, increase stress, and misalign resident needs with hospital protocols. Nearly fifty percent of LTC residents in Canada experience hospital transitions annually, with approximately forty percent considered avoidable. Risks include non-evidence-based care, safety concerns, unnecessary interventions, and increased mortality rates. Transition decisions are influenced by residents' health status, medico-legal concerns, staff workload, and care partners' confidence in LTC care. These decisions are often reactive and shaped by unequal power dynamics rather than proactive, collaborative planning.
Given these challenges, and limitations in current monitoring systems such as the Minimum Data Set assessments, there is a critical need for a decision aid that supports informed, resident-centered planning. The Supporting Transitions and Empowering Preferences (STEP) tool was developed through interviews, co-design sessions, document analysis, and stakeholder engagement.
Objectives Primary Objective: Evaluate the impact of STEP on decisional conflict among residents and care partners.
Secondary Objective: Examine the effect of STEP on nurses' self-efficacy as decision coaches at the time of transition decisions.
Trial Design and Study Setting: A pre-post evaluation will be conducted at two LTC sites (Perley Health and Bruyère Health Saint-Louis LTC) to assess STEP's ability to support resident-care partner dyads in making hospital transition decisions. STEP will be implemented simultaneously at both sites.
Study Overview: Data will be collected for six months pre-intervention or until the target sample size is reached (n=100), followed by the intervention period. Nurses, nurse practitioners, social service workers, and physicians will receive STEP training, with designated champions supporting implementation. Data will be collected at three points: after intake/admission meetings, after care conferences, and after acute events in which a transfer is considered.
Vanguard Phase Implementation: An initial vanguard phase involving approximately ten residents over four to six weeks will test feasibility, refine recruitment, and assess staff comfort before broader rollout.
Description of the Intervention (Overview): The STEP intervention includes three resources: (1) an educational booklet about transition decisions, (2) a structured decision aid, and (3) a phone script for nursing staff calling substitute decision-makers at the time of a transfer decision. Staff will be trained on the use of these resources with sessions scheduled to accommodate different shifts. STEP will be introduced at admission (educational booklet), reviewed at post-admission or annual care conferences (booklet + decision aid), and used during acute health events (decision aid + phone script) to guide structured conversations about hospital transfer decisions.
Monitoring Fidelity: Implementation fidelity will be monitored through nurse logs, informal discussions, and champion reports, assessing feasibility, acceptability, and adherence.
Data Collection Procedures (Overview): Dyads will be identified through care reports and hospital transfer notifications, with eligibility verified prior to consent. Data will be collected using secure REDCap software. For nurses, care conference and physician call notes will be reviewed to identify eligible cases. Surveys and brief interviews will assess experiences, confidence, and barriers to STEP use.
Analysis: Analyses will follow an intention-to-treat approach using Generalized Estimating Equations for repeated measures. Differences between groups will be examined using t-tests or chi-squared tests. Missing data will be minimized through follow-up; cases lost after three unsuccessful contact attempts will be excluded from analysis.
Study design
- Primary purpose
- Health services research
- Allocation
- Not applicable
- Intervention model
- Single group
- Masking
- None (open label)
- Number of arms
- 1
- Model description
- This trial uses a pre-post evaluation design at two LTC sites. All participants receive the same intervention (the STEP tool), with no comparison group or randomization to different arms. Outcomes are compared before and after the intervention within the same group (resident-care partner dyads and nurses).
| Arm | Type | Receives |
|---|---|---|
| STEP Intervention | Experimental | Behavioral: STEP Decision Support ToolkitParticipants (resident-care partner dyads) in this arm will receive the STEP intervention. STEP is a decision aid designed to support shared decision-making about whether to transfer to hospital or remain in LTC during acute health events. It includes an educational booklet, a structured decision aid, and a staff phone script used at three points in the resident's care journey: (1) upon LTC admission, (2) during annual care conferences, and (3) at the time of an acute medical event. LTC nurses will receive training to deliver the STEP tool and support residents and care partners in making informed, values-based transition decisions. |
Who may qualify
- Ages
- 55 years and older
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Adult, Older adult
Key inclusion criteria (10 listed)
- Must be residents of either Perley Health or Bruyère Health Saint-Louis LTC home.
- Residents must be 55 years of age or older.
- Must be able to communicate in French or English.
- Both members of the dyad will be included where applicable. For dyads in which residents do not have the capacity to participate, inclusion will occur through the involvement of their substitute decision-maker (e.g., power of attorney for personal care).
- Must be a nurse, nurse practitioner, social service worker or physician actively involved in care planning, annual conferences, or managing acute health events at Perley Health or Bruyère Health.
Key exclusion criteria (0 listed)
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| STEP Decision Support ToolkitThe STEP toolkit includes (1) an educational booklet provided upon admission and annually, (2) condition-specific decision aids addressing common clinical scenarios, and (3) structured phone scripts for staff. STEP empowers residents and care partners to actively engage in decision-making, promotes care aligned with personal values, and supports staff in facilitating advance care planning to reduce unnecessary or complex transitions. | Behavioural | STEP Intervention |
Primary outcome
Decisional Conflict
Time frame: Administered by Research Assistant 1-6 weeks after a transition decision.
Measured using the Decisional Conflict Scale (16 items; each rated on a 5-point scale; standardized total score 0-100, with higher scores indicating greater decisional conflict and worse decision-making outcomes).
3 secondary outcomes
Decision Self-Efficacy
Time frame: Administered by Research Assistant 1-6 weeks after a transition decision and periodically thereafter.
Transition Rate
Time frame: Measured continuously during the 6 months pre-intervention and 6 months post-intervention periods.
Resident Health Outcomes Post-Transition
Time frame: Measured continuously during the 6 months pre-intervention and 6 months post-intervention periods.
Results and safety
This study is still under way. Results are not available in the source record yet.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 6 Feb 2026.
- Background: PubMed 27665753Tappen RM, Elkins D, Worch S, Weglinski M. Modes of Decision Making Used by Nursing Home Residents and Their Families When Confronted With Potential Hospital Readmission. Res Gerontol Nurs. 2016 Nov 1;9(6):288-299. doi: 10.3928/19404921-20160920-01. Epub 2016 Sep 27.
- Background: PubMed 36413591Marincowitz C, Preston L, Cantrell A, Tonkins M, Sabir L, Mason S. What influences decisions to transfer older care-home residents to the emergency department? A synthesis of qualitative reviews. Age Ageing. 2022 Nov 2;51(11):afac257. doi: 10.1093/ageing/afac257.
- Background: PubMed 28032826Gruneir A, Bronskill SE, Newman A, Bell CM, Gozdyra P, Anderson GM, Rochon PA. Variation in Emergency Department Transfer Rates from Nursing Homes in Ontario, Canada. Healthc Policy. 2016 Nov;12(2):76-88.
- Background: PubMed 21029997Gruneir A, Anderson GM, Rochon PA, Bronskill S. Transitions in long-term care and potential implications for quality reporting in Ontario, Canada. J Am Med Dir Assoc. 2010 Nov;11(9):629-35. doi: 10.1016/j.jamda.2010.07.007.
- Background: PubMed 30442040Cummings GG, McLane P, Reid RC, Tate K, Cooper SL, Rowe BH, Estabrooks CA, Cummings GE, Abel SL, Lee JS, Robinson CA, Wagg A. Fractured Care: A Window Into Emergency Transitions in Care for LTC Residents With Complex Health Needs. J Aging Health. 2020 Mar;32(3-4):119-133. doi: 10.1177/0898264318808908. Epub 2018 Nov 15.
- Background: PubMed 28680944Abraham S, Menec V. Transitions Between Care Settings at the End of Life Among Older Homecare Recipients: A Population-Based Study. Gerontol Geriatr Med. 2016 Dec 15;2:2333721416684400. doi: 10.1177/2333721416684400. eCollection 2016 Jan-Dec.
- Background: PubMed 40444661Menard A, Singh Y, Adams M, Bai JQA, Kobewka D, MacLeod KK. "We Didn't Ask to Be Sick:" Equipping Residents and Care Partners for Transitions From Long-Term Care to Hospital. J Am Geriatr Soc. 2025 Aug;73(8):2410-2421. doi: 10.1111/jgs.19535. Epub 2025 May 30.
- Background: PubMed 39615892Menard A, Konikoff L, Adams M, Singh Y, Scott MM, Yin CY, Kimura M, Kobewka D, Fung C, Isenberg SR, Kaasalainen S, Kierulf J, Molnar F, Shamon S, Wilson K, Kehoe MacLeod K; Ottawa Hospital Research Institute and Bruyere Health Research Institute. Supporting resident-centred decision-making about transitions from long-term care homes to hospital: a qualitative study protocol. BMJ Open. 2024 Nov 29;14(11):e086748. doi: 10.1136/bmjopen-2024-086748.
- Individual participant dataSharing planned: No. Given the small sample size, the sensitive nature of data collected in long-term care settings, and the potential risk of participant re-identification, we do not plan to share IPD publicly. However, IPD may be shared on a case-by-case basis in response to reasonable, ethically approved requests. Aggregate results will be disseminated through publications and presentations.
Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part.
2 sites in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A study testing STEP Decision Support Toolkit in people with LTC-to-hospital Transfer Decision-making, run by Bruyère Health Research Institute. at 2 sites in Canada.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 10 inclusion and 0 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: looking for participants now, as of the sponsor's last update on 6 Feb 2026. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 2 sites in Canada. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
This study is still under way. Results are not available in the source record yet.
How can a doctor refer a patient or contact the research team?
Contact Daniel Kobewka, MD (613-798-5555 ext. 13056, DKobewka@toh.ca), or a site near the patient. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Decisional Conflict (time frame: Administered by Research Assistant 1-6 weeks after a transition decision.). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT07153341, which also lists 8 linked publications.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 6 Feb 2026.