Bridging the Gap: Creating a Continuum of Care

Официальное название

Bridging the Gap: Creating a Continuum of Care Through Active Follow-up by a Case Manager After Discharge - a Controlled Study

Обзор

Coordination and integration between care settings is essential for the quality of care of frail older patients. An active follow-up by a case manager (CM) after discharge form an acute geriatric hospital ward has the potential to bridge the gap between hospital, primary and municipality care for frail older people. This study evaluates the effects of an active follow-up by a CM in primary care after discharge from a geriatric ward, with the following research questions: Can an active follow-up by CM for frail older people discharged from an acute geriatric ward, compared to those not receiving active follow up, Maintain/increase independence in activities of daily living, self-rated health and life satisfaction? Increase satisfaction with health care? Reduce health care consumption/be cost-effective? How feasible is the intervention and the study design from the perspective of the caregivers and the older person? This is a clinical controlled study with a process evaluation. Inclusion criteria are 75 years or older, frail and admitted to a geriatric ward. This study is relevant since today's highly specialized acute care is poorly adapted to the comprehensive needs of frail older people, and exposes them to avoidable risks such as loss of functional capacities causing unnecessary care needs and decreased wellbeing. Active follow-up by a CM after discharge may be an important way to integrate the care for frail older people, after receiving in-hospital geriatric care. This can improve the quality of care for this vulnerable group, and direct the right health care actions towards those in most need. The intervention is a active follow-up after discharge by a CM (nurse) in primary care. CM will secure that discharge and care plans are executed and to address new needs. If there are unmet needs, the CM will ensure that adequate actions are performed to meet the needs. The intervention group consists of participants discharged to a primary health care centre with a CM, who actively follows-up after discharge. The control group consists of participants discharged to a primary health care centre without CM, and thereby no active follow-up after discharge. All participants will be followed-up by the research team during one year, concerning dependence in activities of daily living, self-rated health, health care consumption and satisfaction with care.

Вмешательства

• Другое Intervention group Case Manager (CM)
  The CM will be informed about the discharge plan from the nurse at the geriatric ward, as will the municipality for those with need of home help care. An outline of the intervention has been created with managers from primary care and rehabilitation within primary care and municipality care. Core components in the intervention will be active follow-up of the discharge, rehabilitation and care plans. If there are plans that have not been executed or unmet needs, the CM will take adequate contacts
• Другое Control Group
  The participants in the control group with a planned follow-up by a primary health care centre within the catchment area of the Sahlgrenska University Hospital that does not have CMs designated for active follow up of discharged frail older people. Thus, the participants in the control group will not actively be followed-up after discharge.

Первичные конечные точки

• Dependency in Activities of Daily Living (ADL) [Срок оценки: Baseline to 12 months]

Вторичные конечные точки (4)

• Self-rated health [Срок оценки: Baseline to 12 months]
• Life satisfaction [Срок оценки: Baseline to 12 months]
• Satisfaction with quality of care [Срок оценки: Baseline to 12 months]
• Health economics [Срок оценки: 12 months]

Критерии участия

Критерии включения

75 years or older, screened as frail, admitted to an acute geriatric ward working according to CGA at the Sahlgrenska or Mölndal hospital. Both hospitals are part of Sahlgrenska University hospital, with the same catchment area, including Gothenburg with surrounding municipalities. People in the region can seek care at both hospitals. The orthopaedic clinic is situated at Mölndal hospital, resulting in most patients with fractures being admitted to this hospital, irrespective of in which municipality they are living. Cognitive impairment is not an exclusion criterion. For people who cannot give informed consent due to cognitive impairment, next of kin will be asked to assist with the consent.

Критерии исключения

Less that 75 years old, Not residing in a permanent residence.

Критерии приведены из реестра в оригинале (на английском). Окончательную оценку соответствия проводит исследовательский центр.

Здоровые добровольцы: Нет

Дизайн исследования

Распределение

Нерандомизированное

Модель

Параллельные группы

Маскирование

Простое слепое

Основная цель

Поддерживающая терапия

Центры проведения

Швеция · 1 центр

• University of Gothenburg — Gothenburg

Идентификаторы

NCT: NCT06368674 · 2023-00363

Первоисточники (государственные реестры)

• ClinicalTrials.gov (NIH, США)

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