Care in the Community and at Home Improving hospital-to-home care transitions

Maureen Markle-Reid, McMaster University
Maureen Markle-Reid, McMaster University
Carrie McAiney, University of Waterloo
Carrie McAiney, University of Waterloo

Community Assets Supporting Transitions (CAST): A pragmatic effectiveness-implementation trial to evaluate a hospital-to-home transitional care intervention compared to usual care for older adults with multiple chronic conditions and depression.


  • Depression is one of the most common mental health problems affecting older adults, yet only 12% of those with depression receive adequate treatment. Transitioning from hospital-to-home is a risk factor for depression, particularly in older adults with multiple health conditions and few social supports.
  • Many of these patients rely on care from their general practitioner or family doctor, but depression is often not recognized and treated in older adults. In addition, when older adults are discharged from hospital, very few have a follow-up appointment within one week of leaving the hospital.
  • These patients are at higher risk of requiring more expensive health services &/or rehospitalization for depressive symptoms when they return home.


  • Researchers with the Aging, Community and Health Research Unit (ACHRU) are evaluating the Community Assets Supporting Transitions (CAST) program. This new hospital-to-home transitional care program aims to reduce depressive symptoms, improve patients’ quality of life and self-management ability, and support family caregivers. Researchers will determine the effects, implementation, and costs of CAST, a 6-month program that is being delivered by Registered Nurses who support patients transitioning from hospital to home through in-home visits, telephone follow-up, and care coordination. The researchers are working side-by-side with patients, caregivers and providers from three communities in Ontario to tailor the intervention to each community. The three partner communities include Sudbury, Burlington and Hamilton.

Patient engagement

  • Patients are engaged in all aspects of the project including priority setting, research design, implementation and knowledge transfer. Three patient/caregiver representatives have been recruited as co-investigators and will serve as members of the Patient/Caregiver Ad Hoc Advisory Group.
  • Community Advisory Board members (i.e., patients, caregivers, and health and social service representatives) in each study region have used their understanding of the strengths and needs of each community to provide advice on how the intervention is put in place in their community.

More information on this is study is available on the Aging, Community and Health Research Unit website: