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.