Frailty, Primary Care, Readmission, Transition
Conditions
Keywords
frailty, readmission, transition, discharge, primary care
Brief summary
The purpose of this study is to determine whether discharge follow-up visit by primary physician and community-based nurse affects the risk of early re-hospitalisation among high risk older people discharged from a medical ward.
Interventions
BEHAVIORALReceive municipality-based follow-up visit
Systematic electronic referral from hospital to municipality of high risk people at discharge from a medical ward. Contact from municipality service to primary physician and citizen, to arrange first home visit within 7 days with focus on: medication, rehabilitation plan and health care appointments, functional level and need for further health care initiatives. The visit is concluded by planning of further visits (up till tree) and division of responsibilities between primary physician and the municipality service.
Sponsors
Region Sjælland
Danish Institute for Public Health
Holbaek Sygehus
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
PREVENTION
Masking
SINGLE (Investigator)
Eligibility
Sex/Gender
ALL
Age
65 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Patient geography (The participant live in; Holbæk Kommune, Odsherred Kommune or Kalundborg Kommune.) * Discharged from medical ward Holbæk Sygehus. * Frailty (Rated by following criterion: dementia or a minimum of two of the following conditions; two or more hospitalisations within 12 month prior to follow up, los of physical function, treatment of two or more concurrent medical and/or surgical conditions, psychiatric disease, multi-pharmacy of more than 6 prescription medication, suspicious of congenital disturbances, substance abuse problem, disadvantaged social network, need for increasing home care following index hospitalization.)
Exclusion criteria
* Not discharged to home (If the patient are not discharged to home.) * No written consent (If the patient does not wish to participate / written consent are not signed.)
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Re-admission | Within 30 days from discharge | The primary outcome is re-hospitalisation rate within 30 days from discharge. Data is obtained from the official register of danish patients (Landspatientregistret). |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Long-term hospitalization rate | Within 180 days from discharge | Secondary outcome concerns hospitalization rate measured at 30 and 180 days post discharge. Data is obtained from the official register of Danish patients (Landspatientregistret). |
Other
| Measure | Time frame | Description |
|---|---|---|
| Long-term death rate | Within 180 days from discharge | Other pre-specified outcome concerns death rate measured at 30 and 180 days post discharge. Data is obtained from the official register of Danish patients (Landspatientregistret). |
| Long-term use of primary health care services | Within 180 days from discharge | Other pre-specified outcome concerns the use of primary health care services measured at 30 and 180 days post discharge. Data is obtained from the official register of primary health care in Denmark (Sygesikringsregistret) and registration from 3 Danish municipalities. |
| Long-term use of secondary health care services | Within 180 days from discharge | Other pre-specified outcome concerns the use of secondary health care services measured at 30 and 180 days post discharge. Data is obtained from the official register of Danish patients (Landspatientregistret). |
Countries
Denmark
Outcome results
None listed