Rrisk for unplanned rehospitalizations in multimorbid patients discharged from the hospital Other
Conditions
Interventions
Current interventions as of 29/10/2024:
The multimodal intervention includes several transitional care components per discharge phase: pre-discharge, bridging, and post-discharge interventions.
Pre
• Potentially adjustments to medications based on the treatment plan
• Medication adherence, structured needs assessment to organize missing medications or material (e.g. wound dressings), id
Sponsors
Kantonsspital Baden
Eligibility
Sex/Gender
All
Age
18 Years to 100 Years
Inclusion criteria
Inclusion criteria: Current participant inclusion criteria as of 25/11/2024: Patients =18 years old with a high risk (estimated risk =20%) for unplanned rehospitalization who consent to participate are included in this RCT, if they meet the following inclusion criteria: 1. Hospital inpatients with a high risk (estimated risk =20%) for unplanned rehospitalization (BARRS-Score of =5 points) who are scheduled for discharge to their home 2. Patient and/or proxy must be able to give written informed consent 3. Patient and/or proxy must be able to communicate in German _____ Previous participant inclusion criteria as of 29/10/2024 to 25/11/2024: 1. Hospital inpatients with a high risk (estimated risk =20%) for unplanned rehospitalization (BARRS-Score of =5 points) scheduled for discharge to their home 2. Patient must be able to give written informed consent _____ Previous participant inclusion criteria: 1. Hospital inpatients with a BARRS-Score of =5 points scheduled for discharge to their home 2. Patient must be able to communicate in the German language 3. Patient must be able to give written informed consent
Exclusion criteria
Exclusion criteria: Current participant exclusion criteria as of 25/11/2024: Patients are excluded if they meet the following criteria: 1. Discharge to other institutions (e.g., rehabilitation facilities, nursing homes); 2. Patients or proxy that are not able to understand the trial (e.g., cognitive impairment, language barrier); 3. Anticipated death within 30 days of the trial period; 4. Planned hospitalization within the next 30 days; 5. Unacceptable distance for home visits (>20 km away from the hospital); 6. Prior participation in the current trial (electronic health record will be labeled). _____ Previous participant exclusion criteria as of 29/10/2024 to 25/11/2024: 1. Discharge to other institutions (e.g., rehabilitation facilities, nursing homes); 2. Patients that are not able to understand the trial (e.g., cognitive impairment, language barrier); 3. Anticipated death within 30 days of the trial period; 4. Planned hospitalization within the next 30 days; 5. Unacceptable distance for home visits (>20 km away from the hospital); 6. Prior participation in the current trial (electronic health record will be labelled). _____ Previous exclusion criteria: 1. Patients discharged to other institutions, including rehabilitation facilities, nursing homes 2. Inability/unwillingness to give informed consent, e.g. due to cognitive impairment or language barrier 3. Patients who are scheduled for a planned hospitalization within the next 30 days 4. Patients who live more than 20 km away from the hospital 5. Previous participation in the trial
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Current primary outcome measure as of 29/10/2024: The primary outcome is the rate of first unplanned rehospitalizations within 30 days after discharge from the index admission. An unplanned rehospitalization is defined as an unscheduled admission to any hospital and any division within 30 days after discharge. _____ Previous primary outcome measure: The rate of unplanned rehospitalizations in the high-risk group (BARRS score =5) at 30 days after discharge. Planned (elective) rehospitalizations will not be counted as events. This information is collected by a phone call at 30 days after discharge. | — |
Secondary
| Measure | Time frame |
|---|---|
| Current secondary outcome measures as of 29/10/2024: 1. The rate of unplanned rehospitalizations in the high-risk group (BARRS score = 5) 18 days after discharge. 2. Change in quality of life between discharge and 30 days after discharge, using the EQ5D-5L 3. Quality of life after 30 days, using the EQ5D-5L 4. Death within 30 days 5. Health care use (e.g., physicians’ visits, emergency department visits) within 30 days 6. Patient satisfaction with the discharge management at 30 days, using a clinic-specific questionnaire (TEA) _____ Previous secondary outcome measures: 1. The rate of unplanned rehospitalizations in the high-risk group (BARRS score =5) 18 days after discharge. This information is collected by a phone call 30 days after discharge 2. Quality of life measured by EQ-5D questionnaire at discharge and 30 days after discharge 3. Patient satisfaction with discharge management, as measured by the Transition Evaluation Assessment Tool (TEA) at 5 days after discharge | — |
Countries
Switzerland
Outcome results
None listed