Using a systems engineering, human-centered design process to integrate elements of age-friendly care into structures and processes of evidence based hospital-to-home transition interventions

This innovative study will address suboptimal outcomes (readmission, morality, and loss of function) consistently associated with older adult hospital-to-home transitions by integrating elements of age- friendly care into structures and processes of evidence-based hospital-to-home transition interventions. Existing hospital-to-home transition interventions include aspects of safe transitions, and they provide evidence-based structures and processes of effective transitions. However, existing hospital-to-home transition interventions have lacked elements of high-quality geriatric (i.e., “age-friendly”) care. These include what matters to the individual, and key safety issues (potentially inappropriate medications, falls, cognitive impairment, depression) contributing to loss of function, readmission, and mortality. The 4Ms framework is an ideal starting point for refocusing hospital-to-home transitions because it: 1) starts with “what matters” to the older person and caregivers and 2) outlines best practices for addressing safety issues (medications, mobility, mentation) contributing to suboptimal outcomes during hospital-to- home transitions. The critical gap in the science is how to integrate elements of age-friendly care into older adult hospital-to-home transitions. We propose to conduct stage 0 and 1A research to create the Age-Friendly Hospital-to-Home Transition Intervention (ARRIVE-AT-HOME). We will use a systems engineering, human-centered design process to integrate elements of age-friendly care into structures and processes of evidence-based hospital-to-home transition interventions. Aims of this study are to: 1) identify and prioritize barriers and facilitators to integrating elements of age-friendly care (4Ms) into hospital-to-home transitions from the perspective of multiple key stakeholders; and 2) co-design an adaptable Age-Friendly Hospital-to-Home Transition Intervention (ARRIVE-AT-HOME). In Aim 1, we will conduct interviews with key stakeholders (recently hospitalized older adults, caregivers, healthcare professionals, administrators, and community-based service professionals) to identify barriers and facilitators and then apply systems engineering risk prioritization methods, surveying stakeholders to rate identified barriers and facilitators on frequency, modifiability, and importance. In Aim 2, two design teams will participate in parallel co-design sessions guided by our five-stage design process. One team will include recently hospitalized older adults and unpaid caregivers and the other will include professionals and administrators from hospitals/primary care and community-based services. The expected outcome of this research is an intervention ready for feasibility testing and subsequently a hybrid efficacy/ effectiveness trial testing the intervention’s effectiveness on individual and healthcare utilization outcomes. The proposed aims directly address National Institute on Aging priorities to develop effective interventions to maintain health, well-being, and function. Project Number: 1R21AG089275-01A1 | Fiscal Year: 2026 | NIH Institute/Center: National Institute on Aging (NIA) | Principal Investigator: Daniel LIEBZEIT (+1 co-PI) | Institution: UNIVERSITY OF IOWA, IOWA CITY, IA | Award Amount: $462,341 | Activity Code: R21 | Study Section: Interdisciplinary Clinical Care in Specialty Care Settings Study Section[ICSC] View on NIH RePORTER: https://reporter.nih.gov/project-details/11138277