Geriatric Care, Multimorbidity, Transitional Care
Conditions
Keywords
Transitional Care, Frailty, Rehospitalisation, Geratric Care
Brief summary
This clinical trial at the University Department of Geriatric Medicine FELIX Platter in Basel, Switzerland, is designed to evaluate a new transitional care model aimed at helping frail older adults after they get discharged from the hospital. The AdvantAGE study aims to explore the following questions: * Does the new care model help reduce the number of patients who need to return to the hospital within 90 days? * How effective is the implementation of this care model? Participants in the trial will be followed by advanced practice nurses for up to 90 days after hospital discharge. The patients and their caregivers will receive support in coordinating care, managing medications, and learning to manage the patient's health conditions on their own. Additionally, they will have the opportunity to engage in discussions about advanced care planning.
Interventions
A newly developed care model to support frail older adults during their transition from hospital to home.
Sponsors
Health Department of the Canton of Basel-Stadt
Thekla Brunkert
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Intervention model description
Hybrid effectiveness-implementation study (type 1)
Eligibility
Sex/Gender
ALL
Age
65 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Currently admitted to the acute or rehabilitation ward of University Department of Geriatric Medicine * Reside in Basel-Stadt * Possess the ability to speak and comprehend the German language * Scheduled to be discharged to their home * 65 years or older * Identified by a clinician as having a high risk of deterioration due to frailty Additionally, participants must meet at least one of the following criteria: * diagnosed with a complex chronic disease requiring support in self-management and disease management, or * facing socially challenging situations such as living alone without a supportive network or lacking a GP, or * admitted for an acute illness with a brief hospital stay (e.g., infection, cardiac decompensation) and need support in self- and disease management, and continuity of the therapy plan, including close monitoring.
Exclusion criteria
* residing in a nursing home or being newly admitted to one * lacking informal caregivers and exhibiting severe cognitive impairment (MMS ≤23) * scoring \<50 on the motoric domain of the Functional Independence Measure (FIM) * having a psychiatric disorder that significantly impacts their ability to manage daily life at time of the discharge
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| 90-days rehospitalization rate | 90 days post-discharge | Number of unplanned hospital admissions of any kind happening within 90 days after discharge |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Time to readmission | Up to 90 days post-discharge | Number of days between hospital discharge and unplanned hospital admission |
| Number of emergency room visits | 90 days post-discharge | Number of emergency room visits (with or without hospital admission) within 90 days after discharge |
| 30-days rehospitalization rate | 30 days post-discharge | Number of unplanned hospital admission of any kind happening within 30 days after discharge |
| Patient's health-related quality of life | Up to 90 days post-discharge | The EuroQoL-5D-5L is used to assess the health-related quality of life in patients at three time points. Prior to hospital discharge, 7 days and 90 days after hospital discharge or if the patient completed the intervention |
| Patient satisfaction questionnaire | up to 90 days post-discharge | Satisfaction regarding intervention participation |
| Time to emergency room visit | Up to 90 days post-discharge | Number of days between hospital discharge and emergency room visit |
Countries
Switzerland
Contacts
Primary ContactMario Ernst
Backup ContactIsabel Pfundstein
Outcome results
None listed