Care Coordination, Geriatric, Readmission, Hospital
Conditions
Keywords
Geriatrics, Mobile Geriatric Team, Care coordination, Social recommandations, Elderly care, Hospital readmission
Brief summary
This single-center, prospective, observational cohort study aims to evaluate the actual implementation rate of social recommendations formulated by the Mobile Geriatric Team at Saint-Étienne University Hospital three months after hospital discharge. These recommendations may include human assistance, technical aids, financial aid applications, legal protective measures, or referrals to appropriate care structures. A structured telephone interview at three months will assess the degree of implementation, explore associated barriers (administrative, cognitive, organizational, ...), and investigate any potential link with hospital readmissions or changes in patients' living situations.
Interventions
OTHERTelephone interview
A structured telephone interview at three months will assess the degree of implementation, explore associated barriers (administrative, cognitive, organizational, ...), and investigate any potential link with hospital readmissions or changes in patients' living situations.
Sponsors
Centre Hospitalier Universitaire de Saint Etienne
Study design
Observational model
COHORT
Time perspective
PROSPECTIVE
Eligibility
Sex/Gender
ALL
Age
75 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Patients aged 75 years or older * Patients assessed by the Mobile Geriatric Team of the Saint-Etienne University Hospital with the formulation of social recommendations * Patients residing at home or in a long-term care facility for dependent elderly individuals (nursing home / EHPAD) * Informed consent obtained from the patient or their legal representative
Exclusion criteria
* Patients under 75 years old * Refusal to participate in the study by the patient (or by the legally authorized representative/trusted person). * Patients receiving exclusive palliative care * Inability to ensure follow-up: in case of non-response at three months or in the event of death
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Rate of implementation of social recommendations | Month : 3 | Evaluate the three-month implementation rate of the total social recommendations issued by the mobile geriatric team. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Factors hindering the implementation of recommendations | Month : 3 | Identify the factors holding back the implementation of TOTAL recommendations (then SPECIFIC: human, technical, financial, patient orientation, implementation of legal protection measures). |
| Reasons for refusal or non-implementation | Month : 3 | Analyze the reasons for refusal or non-implementation. |
| Impact of non-implementation on the re-hospitalization rate | Month : 3 | Evaluate the impact of non-implementation on the re-hospitalization rate. |
| Patient's living environment | Month : 3 | Document changes in the patient's living environment at three months. |
Countries
France
Contacts
Primary ContactManon SAHUC
Outcome results
None listed