Table 2.

Description of intervention components

DIVERT-CARE intervention components	Description
Case finding using the DIVERT Scale	Use of the DIVERT Scale (embedded in interRAI assessment) to identify home care clients most likely to benefit.
Self-management education and supports	In-home assessment of self-management goals and needs, with practical education and skills training to recognise and manage symptoms.
Access to an immediate nurse-staffed helpline	Direct phone line staffed by nurses involved in the DIVERT-CARE intervention to aid with self-management and problem resolution.
Promotion of vaccines	Seasonal influenza vaccine and pneumococcal polysaccharide (Pneu-P-23) information and health promotion consistent with Canadian practice guidelines.
Advance care and goal planning	Consultation for advance care and goals of care planning, advanced care decisions and communication of care wishes.
Clinical pharmacist-led medication review	Review of medication for safety, efficacy and appropriate use of medications and delivery options.
Interprofessional team case rounds	Weekly or biweekly care team meeting to discuss care plan, update goals, and how to support changing care needs.
SBAR communication with primary care providers	SBAR formatted communication to effectively communicate disease relevant information and care updates to primary and specialist care providers.
Standardised ED transition package/personal care record	A succinct document to support continuity of care throughout health system. Personal care record of goals, plan of care and community supports.

CARE, Collaboration Action Research and Evaluation; DIVERT, Detection of Indicators and Vulnerabilities of Emergency Room Trips; ED, emergency department; SBAR, situation, background, assessment, and recommendation.