None listed
Conditions
Brief summary
At least 20% of older people that are seen in a hospital emergency department and discharged will reattend the ED within 28 days. There are many negative consequences associated with ED reattendance and rehospitalisation soon after discharge. We will conduct a randomised trial to determine whether referral to and intervention by a Complex Needs Coordination Team after discharge can reduce the risk of ED reattendance.
Interventions
Care coordination commenced by a research team member within 72 hours of ED discharge.
We will conduct a home assessment to supplement assessments done prior to discharge, and in conjunction with the patient formulate specific plans based around identifiable risks. Initial contact will involve establishment of rapport and commencement of assessment including assisting the patient (+/- family/carer as appropriate) to express their understanding of their risk for early re-presentation and potenti
Care coordination commenced by a research team member within 72 hours of ED discharge. We will conduct a home assessment to supplement assessments done prior to discharge, and in conjunction with the patient formulate specific plans based around identifiable risks. Initial contact will involve establishment of rapport and commencement of assessment including assisting the patient (+/- family/carer as appropriate) to express their understanding of their risk for early re-presentation and potentially modifiable contributing factors. Further information will then be provided to the patient regarding their identifiable risks found on risk assessment, and what services may be available so that the patient can make an informed choice regarding their options. Research staff will have a coordinating and advisory role assisting the patient/carer in invoking these plans. These will be directed towards addressing where possible risks found from our risk algorithm which was used to identify the patient at high risk of re-presentation. It is estimated that the duration of initial home assessment will be 1.5 hours, and on average this will be followed by 2x1 hour further face to face sessions and 20 minute weekly telephone contact for a minimum of 4 weeks
Sponsors
University of Western Australia
Study design
Allocation
Randomised controlled trial
Intervention model
Parallel
Primary purpose
Treatment
Masking
Open (masking not used)
Eligibility
Sex/Gender
All
Age
65 Years to No maximum
Healthy volunteers
No
Inclusion criteria
1. Age at least 65 years old 2. Live in geographical area of Perth Western Australia covered by post discharge community services 3. Identified as high risk (approximately 35% or higher probability) for re-presentation based on our risk algorithm 4. Informed consent 5. Meet occupational health and safety policy on safe home and community visiting
Exclusion criteria
1. Resident of high level aged care facility 2. No fixed residential address 3. Currently under palliative care services, or deemed not likely to survive longer than 90 days 4. Discharged without ED care coordination team assessment
Outcome results
None listed