Recruiting

STEP Toolkit

Sponsor:

Bruyère Health Research Institute.

Code:

NCT07153341

Conditions

LTC-to-hospital Transfer Decision-making

Eligibility Criteria

Sex: All

Age: 55+

Healthy Volunteers: Not accepted

Interventions

STEP Decision Support Toolkit

Study Details

Brief 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.

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.

Conditions

LTC-to-hospital Transfer Decision-making

Study ID

NCT07153341

Start date

Oct 1, 2025

Status verified date

Jan, 2026

Completion date

Sep 1, 2027

Anticipated

Primary completion date

Mar 4, 2026

Anticipated

Eligibility Criteria

Eligibility Criteria

Sex: All

Age: 55+

Healthy Volunteers: Not accepted

Inclusion Criteria

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:

  • 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.

Study Design

Enrollment

200 participants

Anticipated

Intervention Model

Single group

Primary purpose

Health Services Research

Interventions and Outcome Measures

Arms

experimental: STEP Intervention

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.

Interventions

STEP Decision Support Toolkit

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.

Primary outcome measure

  • Decisional Conflict [ Time Frame: Administered by Research Assistant 1-6 weeks after a transition decision. ]

Central Contacts and Locations

Central contacts

Daniel Kobewka, MD

613-798-5555DKobewka@toh.ca

Alixe Ménard, MSc, PhD(c)

613-798-5555alimenard@ohri.ca

Locations

Bruyère Health Saint-Louis Long-Term Care

Recruiting

Ottawa, Ontario, Canada, K1C 2Z6

Perley Health

Recruiting

Ottawa, Ontario, Canada, K1G 4B2

More Information

Sponsor

Bruyère Health Research Institute.

Last update posted

Feb 6, 2026

Last verified

Jan, 2026

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

Trial information was received from ClinicalTrials.gov and was last updated on 2026-09-10. This information was provided to ClinicalTrials.gov by Bruyère Health Research Institute. on 2026-02-06.