Elderly, aged, older, geriatric, functional decline, functional loss, cadiovascular disease, heart failure, acute myocardial infarction, transitional care, disease management, case management, home-based cardiac rehabilitation, readmission, rehospitalization, mortality Ouderen, geriatrie, functionele achteruitgang, functieverlies, cardiovasculaire aandoeiningen, hartfalen, acuut myocardinfarct, transmurale zorg, diseasemanagement, casemanagement, hartrevalidatie, heropname, overlijden
Conditions
Interventions
Patients admitted to the department of cardiology or cardiac surgery of > 70 years, at high risk of functional loss and admitted > 48 hours are eligible for inclusion. The program combines case manage
Sponsors
Academic Medical Center (AMC), Amsterdam, The Netherlands
Eligibility
Inclusion criteria
Inclusion criteria: - 70 years and older - Admitted patients to the departments of cardiology or cardiac surgery - Admission > 48 hours - High risk of functional decline according to the VMS screening-tool for frailty of the Dutch Safety Management Program (screening on ADL-functioning, fall risk, malnutrition and delirium): score >=2 in patients aged 70-79 years and score >= 1 in patients aged 80 years and older - Mini-Mental State Examination Score (MMSE) >= 15 - Per 28 February 2018, patients with an unplanned hospital admission in the previous six months are also eligible for inclusion (independent of the score on the VMS screening tool for frailty)
Exclusion criteria
Exclusion criteria: - Congenital heart disease - Terminal illness: defined as a life expectancy of less than three months, for example because of cancer or serious heart failure. - Transferred from or planned discharge to a nursing home - Planned discharge to another hospital not participating in this study - Unable to communicate in Dutch - Delirium as confirmed by the treating physician
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| The incidence of the composite end-point of first all-cause unplanned hospital readmission or mortality. | — |
Secondary
| Measure | Time frame |
|---|---|
| - The incidence proportion of the composite end-point of first all-cause unplanned hospital readmission or mortality - ADL-functioning and iADL-functioning - Functional capacity - Medication adherence - Anxiety - Depression - Health-related quality of life - Healthcare utilization - Caregiver burden | — |
Contacts
Public ContactBianca Buurman
Postbus 22660
Outcome results
None listed