The study is based among patients deemed to have a high risk of emergency admission Not Applicable
Conditions
Interventions
Each participant assigned to the intervention group will be allocated a designated health coach. Following an initial assessment, the health coach will be in regular contact with the patient by teleph
Sponsors
Health Navigator AB
Eligibility
Sex/Gender
All
Inclusion criteria
Inclusion criteria: 1. Patients residing in the studied region 2. Patients 18 years or older 3. Patients considered to be at high risk of non-elective admissions in the next 6 months according to a risk prediction model. The prediction model is based on patient administrative data, and makes an automated risk assessment based on the patient's sex, number of diagnoses (registered diagnoses in the past 2 years), planned and unplanned hospital contacts in the past 6 months and readmissions. The risk assessment is based on a logistic regression model which will be developed and validated specifically for the study.
Exclusion criteria
Exclusion criteria: 1. Patients who have had contact with healthcare services within the past six months, and have one or more of the following diagnoses (not necessarily the diagnosis relating to their contacts): 1.1. Dementia 1.2. Psychotic disorders 1.3. Mental disorders caused by misuse 1.4. Terminal cancer 2. Estimated remaining life expectancy of < 1 year 3. Has undergone major surgery in the last six months or planned to undergo major surgery in the foreseeable future 4. Severe hearing loss 5. Language difficulties that require an interpreter 6. Level of cognitive ability which is not sufficient for receiving and responding to telephone counselling 7. Does not have access to a telephone connection
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| 1. Emergency hospitalizations, ascertained using hospital electronic medical records 2. Emergency hospital outpatient visits, ascertained using hospital electronic medical records These will be measured at the end of follow-up, i.e. after 2 years. | — |
Secondary
| Measure | Time frame |
|---|---|
| 1. Non-elective bed days, ascertained using hospital electronic medical records 2. Total hospital admissions, ascertained using hospital electronic medical records 3. Total bed days, ascertained using hospital electronic medical records 4. A&E attendances, ascertained using hospital electronic medical records 5. Total health-care costs, ascertained using hospital electronic medical records 6. Patient activation, ascertained using PAM-13 7. Quality of life, ascertained using SF-12 These will be measured at the end of follow-up, i.e. after 2 years. | — |
Countries
United Kingdom
Outcome results
None listed