None listed
Conditions
Brief summary
This trial hopes to improve the quality of life of patients whose age, heart or respiratory condition means that they regularly attend the emergency department. It aims to reduce the number of times patients come to hospital by improving the patient's home-based care plan. To do this, hospital staff will contact the patient's GP and other community-based health providers to discuss the best care plan. The outcomes of these patients will be compared to patients who do not receive this extra care planning.
Interventions
Care Navigation: hospital and community-based care plan development by the Care Navigation nurse, who contacts hospital and community care providers, prior to the discharge of the patient from hospital to discuss the details of the patient's hospital and home care requirements. Participant progress is also followed up after their return home. The study intervention will be given for 24 months from the date of randomisation into the study.
Sponsors
The University of Sydney
Study design
Allocation
Randomised controlled trial
Intervention model
Parallel
Primary purpose
Prevention
Masking
Open (masking not used)
Eligibility
Sex/Gender
All
Age
16 Years to No maximum
Healthy volunteers
No
Inclusion criteria
1. Have had three or more admissions to a Sydney West Area Health Service hospital within a calendar year 2. Patients are either a) greater than 69 years old, irrespective of the diagnosis at any of the three admissions, b) greater than 45 years old and of Aboriginal or Torres Strait Islander decent, irrespective of the diagnosis at any of the three admissions, or c) 16 years or older and less than 70 years old, where at least one of the admissions was for a chronic cardiac or respiratory condition (International Classification of Diseases I11.0, I13.0, I13.2, I25.5, I42, I43, I50 & J40-44); 3. Written informed consent.
Exclusion criteria
1. Patients whose clinical conditions (too acutely sick or bewildered) preclude them from giving informed consent. 2. Patients who have received Care Navigation at another hospital. 3. Patients whose language skills prevent them from completing questionnaires (interpreter and translation services will be provided for patients from culturally and linguistically diverse backgrounds).
Outcome results
None listed