A University of Iowa researcher has won a $462,000 grant from the National Institutes of Health to create a model that eases the transition from hospital to home for older patients. 

Daniel Liebzeit, assistant professor in the UI College of Nursing, will interview, survey and conduct focus groups with older individuals, their caretakers, hospitals, and community-based agencies to build the program. 

He will work with collaborators from Vanderbilt University Medical Center and Johns Hopkins Medicine.

Geriatric patients, defined as adults 65 years of age and older, is the most discharged group from hospitals in the United States, according to the Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services.

While this age group makes up the largest share of discharges, most hospital staff don't have training in geriatrics, Liebzeit says, meaning they may be unable to sufficiently prepare older adults and caregivers in their transition to a home setting.

In addition, most hospitals nationwide use the same care and discharge models for older patient populations as any other age group, Liebzeit says. These models may treat older adults’ immediate medical needs, he says, but they often fail to direct them to community resources or address other needs, such as guidance in regaining mobility, preparing their caretakers to support them, and monitoring changes in their cognitive abilities.

That could lead to greater health risks for older adults, such as falling in their home or making errors with their medication, Liebzeit says.

Liebzeit’s hospital-to-home proposal aims to adapt an existing health care model called the 4M Framework. That framework centers on “what matters most” to the patient (such as staying independent at home), medication, mobility, and mentation (referring to mental health and cognition). 

The 4M Framework is used mostly within settings that deliver care, such as hospitals and skilled nursing facilities. Liebzeit will use the data his team collects to propose a program specifically for the hospital-to-home transition.

“We believe thoughtful integration of the 4Ms framework for age-friendly health systems, centered on what matters most to the older adult and caregiver, can address challenges and improve both health outcomes and the client-professional experience,” Liebzeit says.

 The award from the National Institute on Aging, a branch of the National Institutes of Health, is for two years.