In deze studie zullen patiënten met alle cardiologische aandoeningen worden geïncludeerd op zowel de afdelingen cardiologie als cardiothoracale chirurgie Cardiovascular disease / heart disease
Conditions
Interventions
The intervention starts during the admission for patients randomized to the
intervention group (within 72 hours after hospital admission). A personalized,
integrated care plan based on identified pr
Sponsors
Academisch Medisch Centrum
Eligibility
Age
18 Years to 99 Years
Inclusion criteria
Inclusion criteria: - Cardiac patients of 70 years and older - Admitted to the departments of cardiology or cardiothoracic surgery - Electively and non-electively - Admission > 48 hours - Hisk of functional loss according to the screening-tool for frailty of the Dutch Safety Management Program (screening on ADL-functioning, fall risk, malnutrition and delirium) and/or an unplanned admission in the previous six months - Mini-Mental Examination Score (MMSE) >= 15
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 terminal heart failure. -Transferred from or to a nursing home -Transferred 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 |
|---|---|
| A composite endpoint of unplanned hospital readmission and mortality up to six months after randomizaton | — |
Secondary
| Measure | Time frame |
|---|---|
| Readmissions and mortality within three and twelve months after randomization ADL-functioning iADL-functioning Functional capacity Medication adherence Anxiety Depression Health-related quality of life Symptom burden Healthcare utilization (Regular community care, primary care visits, emergency department visits, hospital readmissions and institutionalization) Caregiver burden | — |
Countries
Netherlands
Outcome results
None listed