I50 J44 N18 E11 E10 I25 I10
Conditions
Interventions
Group 1: Standard hospital care plus additional care in eliPfad:
Screening visit:
1. review of inclusion and exclusion criteria.
Inclusion criteria:
- Acute inpatient admission or transfer to a stand
Sponsors
Universität zu Köln
Eligibility
Sex/Gender
All
Age
55 Years to No maximum
Inclusion criteria
Inclusion criteria: - Acute inpatient admission or transfer to a normal ward of a participating center due to an internal disease (initial admission diagnosis) in the form of: o direct admission from home / from the referring resident HA / FA o Transfer from the in-house emergency room o Admission from an external hospital (reason for admission: internal medicine) o Admission from another care unit within the hospital . - Age = 55 years - multimorbid patients (at least 3 diseases) - At least one of the following index diagnoses: o heart failure (HI) (NYHA I-IV) o Renal insufficiency (NI) o Chronic obstructive pulmonary disease (COPD) o Diabetes mellitus (DM) o Peripheral arterial occlusive disease (pAVK) o Coronary heart disease (CHD) o arterial hypertension - High risk for unplanned readmission (risk assessment using Multidimensional Prognostic Index (MPI) = 0.34). - Written consent, documented by signature, after adequate reflection time. Patient education and consent can only occur outside of an acute medical emergency situation.
Exclusion criteria
Exclusion criteria: - Patients with a non-internal medicine initial reason for admission (this includes the reason for admission for initial admission to an external hospital). - Patients who can be discharged within a maximum of 2 working days - Residents of nursing facilities, 24-hour home care, predominant bedriddenness - lack of rehabilitation potential according to the assessment of the attending physician - insufficient German language skills among patients and relatives / acquaintances - higher degree of visual and/or hearing impairment - illnesses with a life expectancy of less than 6 months - desired rehabilitation on day 1 to 42 after discharge from index hospitalization - distance to the patient's home of significant more than 50 km (individual decision) - Persons who have private health insurance - persons who are in a dependent/employed relationship with the investigators - Lack of business and consent capacity - Placement in an institution by court or official order
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Reduction of unplanned rehospitalisations, defined as a medically determined need for hospitalisation within 24 hours, by emergency services or by patients own initiative, in the study population over 180 month after hospital discharge. | — |
Secondary
| Measure | Time frame |
|---|---|
| - Reduce the length of hospital stays and reduce stays in intensive and intermediate care units. - Reduction of transfers and length of stay in rehabilitation facilities and utilisation of rehabilitation services - Improvement in overall survival - Improvement of clinical outcomes (related to index diagnoses) - Improvement in health-related quality of life - Reduction of depression rates in the target population - Improvement in mobility - Improvement in nutrition - Improvement of subjective health status - Improvement of self-efficacy - Improvement of health literacy - Improved implementation of age-appropriate medication - Improved patient orientation of care - Improved implementation of personal therapy goals / self-management - Minimisation of the burden of therapy by reducing polypharmacy and improving integration and patient-centredness of care System-related: -Inhibiting and facilitating factors of implementation -Health economic evaluation -Cost-effectiveness analysis from a SHI perspective -Process evaluation: satisfaction / acceptance by patients / relatives / service providers | — |
Countries
Germany
Contacts
Public ContactPaul Brinkkötter
Uniklinik Köln
Outcome results
None listed