None listed
Conditions
Brief summary
Older people have higher rates of hospital admission than the general population and higher rates of readmission due to complications and falls. During hospitalisation, older people experience significant functional decline which impairs their future independence and quality of life. Current models of discharge planning and follow-up care do not address the need to prevent deconditioning or functional decline. This study aims to compare the effectiveness of innovative strategies including exercise and/or in-home and telephone follow-up for community-based older people at risk of readmission. Results will determine effective strategies to reduce readmissions and improve functional status, independence and psycho-social well-being
Interventions
Intervention 1. Gerontic Nurse (GN) comprehensive assessment within 72 hours of hospital admission, discharge planning, home visit within 72 hours from discharge, telephone follow-up care weekly for 4 weeks then monthly for 24 weeks post-discharge.
Intervention 2. Physiotherapist comprehensive assessment within 72 hours of hospital admission, individualised exercise program commencing within 72 hours of hospital admission.
Intervention 3. Gerontic Nurse (GN) and Physiotherapist comprehensiv
Intervention 1. Gerontic Nurse (GN) comprehensive assessment within 72 hours of hospital admission, discharge planning, home visit within 72 hours from discharge, telephone follow-up care weekly for 4 weeks then monthly for 24 weeks post-discharge. Intervention 2. Physiotherapist comprehensive assessment within 72 hours of hospital admission, individualised exercise program commencing within 72 hours of hospital admission. Intervention 3. Gerontic Nurse (GN) and Physiotherapist comprehensive assessment within 72 hours of hospital admission, individualised exercise program commencing within 72 hours of hospital admission, discharge planning (GN), home visit within 72 hours from discharge (GN), telephone follow-up care weekly for 4 weeks then monthly for 24 weeks post-discharge (GN).
Sponsors
Professor Mary Courtney
Study design
Allocation
Randomised controlled trial
Intervention model
Parallel
Primary purpose
Prevention
Masking
Blinded (masking used)
Eligibility
Sex/Gender
All
Age
65 Years to No maximum
Healthy volunteers
No
Inclusion criteria
1. Aged 65 years or older 2. Admitted to a hospital wards with a medical (i.e. non-surgical) diagnosis 3. Have at least one of the following known risk factors for hospital readmission: a. aged 75 years or older b. live alone c. poor social support available at home d. 2 or more hospital admissions within the previous 6 months e. previous hopsitalisation in the past 30 days f. moderate to severe functional impairment g. history of depression
Exclusion criteria
1. Unable to be contacted via telephone 2. Resident of a high care nursing home 3. Unable to speak or understand English
Outcome results
None listed