Open Access Research article

The Older Persons’ Transitions in Care (OPTIC) study: pilot testing of the transition tracking tool

Robert Colin Reid1, Garnet E Cummings2, Sarah L Cooper3, Stephanie L Abel3, Laura J Bissell1, Carole A Estabrooks3, Brian H Rowe2, Adrian Wagg4, Peter G Norton5, Mike Ertel6 and Greta G Cummings3*

Author Affiliations

1 School of Health and Exercise Sciences, University of British Columbia’s Okanagan campus, 3333 University Way, ART, Kelowna, British Columbia V1V 1V7, Canada

2 Department of Emergency Medicine, Faculty of Medicine and Dentistry and School of Public Health, University of Alberta, Edmonton, Alberta, Canada

3 Faculty of Nursing, University of Alberta, 5-110 Edmonton Clinical Health Academy, 11405 87 Avenue, Edmonton, Alberta T6G 1C9, Canada

4 Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada

5 Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada

6 Kelowna General Hospital, Interior Health Authority, Kelowna, British Columbia, Canada

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BMC Health Services Research 2013, 13:515  doi:10.1186/1472-6963-13-515

Published: 14 December 2013



OPTIC is a mixed method Partnership for Health System Improvement ( webcite) study focused on improving care for nursing home (NH) residents who are transferred to and from emergency departments (EDs) via emergency medical services (EMS). In the pilot study we tested feasibility of concurrently collecting individual resident data during transitions across settings using the Transition Tracking Tool (T3).


The pilot study tracked 54 residents transferred from NHs to one of two EDs in two western Canadian provinces over a three month period. The T3 is an electronic data collection tool developed for this study to record data relevant to describing and determining success of transitions in care. It comprises 800+ data elements including resident characteristics, reasons and precipitating factors for transfer, advance directives, family involvement, healthcare services provided, disposition decisions, and dates/times and timing.


Residents were elderly (mean age = 87.1 years) and the majority were female (61.8%). Feasibility of collecting data from multiple sources across two research sites was established. We identified resources and requirements to access and retrieve specific data elements in various settings to manage data collection processes and allocate research staff resources. We present preliminary data from NH, EMS, and ED settings.


While most research in this area has focused on a unidirectional process of patient progression from one care setting to another, this study established feasibility of collecting detailed data from beginning to end of a transition across multiple settings and in multiple directions.

Transfers; Transitional care; Transition tracking; Nursing home; Emergency department