Basic population: care-dependent people Diseases investigated for the intensified monitoring: Diabetes mellitus Diseases investigated for the intensified monitoring: Heart failure Diseases investigated for the intensified monitoring:COPD Diseases investigated for the intensified monitoring: Par-kinson’s disease Diseases investigated for the intensified monitoring: Pain E10-E14 I50 I11.0 I13.2 J44 G20 G21 G22 R52 F45.4
Conditions
Interventions
Group 1: Care-dependent people included into the intervention group receive health care by health care services (general practitioners and nursing homes or ambulatory care services) communicating via
Sponsors
AOK Sachsen-Anhalt
Eligibility
Sex/Gender
All
Inclusion criteria
Inclusion criteria: General inclusion criteria: People living in Sachsen-Anhalt can participate in the study. Patients can be included in the period 01.10.2021-30.09.2022. Inclusion criteria communication with THP: Care-dependent persons insured by AOK Sachsen-Anhalt or IKK gesund plus with a care dependence level of 2 or higher, who live in the project region in a nursing home according to §43 Social Code Book XI or receive ambulatory nursing care according to §36 Social Code Book XI and who agree to participate in the project. Inclusion criteria intensive monitoring: Insured persons of the aforementioned group with at least one of the following diseases or conditions: diabetes, heart failure, COPD, Parkinson's disease, pain and an increased need for monitoring in the case of an unstable state of illness at the instigation of the participating general practitioner. Inclusion criteria control group: Care-dependent persons insured by AOK Sachsen-Anhalt or IKK gesund plus with a care dependence level of 2 or higher, who live outside the project region (see Brief Summary in Lay Language) and at least one day during inclusion period in a nursing home according to §43 Social Code Book XI or receive ambulatory nursing care according to §36 Social Code Book XI. Inclusion criteria care providers & general practitioners: General practitioners who declared their participation in the special form of care, as well as outpatient care services and nursing homes in the project region that participate in the special form of care through cooperation agreements.
Exclusion criteria
Exclusion criteria: Insured persons with a care dependence level of 1 or no care dependence level or those who have chosen the cash benefit and/or use day or night care services.
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Rate of unplanned inpatient admissions. The primary end-point will be reviewed after the end of the intervention for the intervention period of 2 years (October 2021 – Sep-tember 2023). For this purpose, healthcare claims data from the participating health insurances will be used. Un-planned hospital admissions are identifiable via the admis-sion reason "emergency". | — |
Secondary
| Measure | Time frame |
|---|---|
| Unplanned ambulatory care; Utilisation of the ambulance; Utilisation of cost-intensive unplanned health care in relation to utilisation of less cost-intensive unplanned health care; Mortality; Average total health care costs; Communication; Utilisation of the telehealth solution; Feasibility of the telehealth solution; Satisfaction | — |
Countries
Germany
Contacts
Public ContactSilke Nagel
AOK Sachsen-Anhalt
Outcome results
None listed