Health News For North East

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Tuesday, April 03, 2018

Community Assets Supporting Transitions (CAST)

Dear North East Local Integrated Network,
We are excited to share with you an innovative, nurse-led intervention to support older adults with depressive symptoms and other chronic conditions as they transition from hospital to home. Community Assets Supporting Transitions (CAST) is a one year study evaluating a 6-month intervention that is being offered to older adults in the Greater Sudbury area who are being discharged from Health Sciences North. Participants must meet the following criteria:
? = 65 years of age;
? have depressive symptoms; and
? have two or more chronic health conditions.
The focus of the intervention is early identification and management of depressive symptoms and other chronic conditions. The goal of the CAST study is to improve patients' self-management ability, support their families and caregivers, and improve health outcomes.
Brianna Charbonneau, RN, B.Sc.Inf, is one the Care Transition Coordinator (CTC) who will be implementing the CAST program in the Greater Sudbury community. She is a Registered Nurse who is excited to be working in research, conducting in-home visits, and caring for older adults who are transitioning from hospital to home. She will work collaboratively with local health and non-health organizations and community agencies to carry out the following activities:
  • Care coordination and system navigation (including facilitation of timely primary care follow-up and linking to needed services and supports);
  • Medication review and management;
  • Health assessment of patients and their family caregivers;
  • Problem-solving therapy and development of self-management strategies; and
  • Patient and family caregiver education.
    The CTC may be communicating with you about patients who are enrolled in the CAST program. Participants will be asked to provide consent for the CTC to contact and exchange personal health information with the patient's care providers and community organizations who are also involved in their care. This will enable the CTC to help with the coordination of the patient’s care.
    If you would like to learn more about the CAST study, or if you have any further questions, please contact the study coordinator, Tracey Chambers, by phone at 905-525-9140 x21626 or email at
    We look forward to working with you and other partners in the Greater Sudbury community, and learning more about what services your organization offers. Thank you for your help with this important study.
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