Development and evaluation of transitional care program for frail older adults

Development and evaluation of transitional care program for frail older adults between hospital and home using mixed methods research

Status

Active, not recruiting

Phases

Unknown

Study type

Interventional

Source

CRIS

Registry ID

KCT0006130

Enrollment

Registered

2021-05-12

Start date

2021-06-04

Completion date

Unknown

Last updated

2025-11-17

For informational purposes only — not medical advice. Sourced from public registries and may not reflect the latest updates. Terms

Conditions

None listed

Interventions

Others : 1. Intervention arm Transitional care program includes following interventions

1) Transitional discharge planning and education: providing structured discharge planning with frail older adults and their family caregiver (providing patient health summary) and information on comm

2) one outpatient clinic visit

3) home visit within 7 days after discharge (approximately 30 minutes): identifying unexpected difficulties and community resource needed

4) six phone follow-up calls (approximately 15 minutes each) within 24 hours after discharge, and at 2, 3, 4, 8, and 12 weeks thereafter. 2. control arm usual care

Eligibility

Sex/Gender

All

Inclusion criteria

Inclusion criteria: 1) Age 65 or more 2) Determined as frail using frailty scale 3) Who are discharged home 4) Living with family after discharge 5) Being able to communication in Korean 6) Who understands the purpose of study and agree to participate

Exclusion criteria

Exclusion criteria: 1) Discharge to a long-term care facility or nursing home 2) Diagnosed with dementia or Mini Mental Status Examination 18 or less 3) Life expectancy less than 1 year or determined as terminally ill condition by physician 4) Admission from nursing home or long-term care facility

Design outcomes

Primary

Measure	Time frame
Functional status;Symptom experiecne;Connectedness;Empowerment;Healthcare service use	—

Secondary

Measure	Time frame
Readiness of discharge;Family function;Community resource utilization	—

Countries

Korea, Republic of

Contacts

Public ContactJi Yeon Lee

Yonsei University Health System, Severance Hospital

lovecolakr@gmail.com+82-2-2228-5444

Outcome results