Improvement of Transition From Hospital to Home for Older Patients in Germany

NCT03513159 | Completed

• 1 other identifier: IBA-2018-TIGER
• Study Type: interventional
• Target: 252
• Locations: 1 country
• Sites: 2

Brief Summary

The aim of the transsectoral care project TIGER is the reduction of readmission rates of geriatric patients. This aim shall be achieved by improving the hitherto inadequate care process for geriatric patients in the transition from hospital to home. The program offers substantial support of patients and their informal caregivers in the transition process from hospital to home via so called pathfinders, specialized nurses in geriatrics.The pathfinders effectively intertwine stationary and ambulatory care teams caring for a patient, thereby augmenting and complementing effective hospital release management.

Conditions

Geriatric Patients in the Transition From Hospital to Home

Keywords

transitional care, geriatric, readmission,; discharge; quality of life

Outcome Measures

Primary Outcomes (1)

• Readmission Rate

  The number of readmissions of a patient into a hospital within up to 15 months (study period for the patient.plus 3 months prior to enrollment).

  up to 12 months

Secondary Outcomes (14)

• Functionality and mobility - 1

  up to 12 months

• Functionality and mobility - 2

  up to 12 months

• Functionality and mobility - 3

  up to 12 months

• Functionality and mobility - 4

  up to 12 months

• Functionality and mobility - 5

  up to 12 months

Study Arms (2)

Pathfinder support

EXPERIMENTAL

Pathfinder support with development of an individual care plan for the intervention patients and their informal caregivers, with the hospital physicians already inside the hospital setting. This will then be developed and improved further during up to twelve months after hospital release with the primary physician. The pathfinders will coordinate the ambulatory care team services and closely involve the primary physicians. The patients and their informal caregivers will be empowered and educated to achieve a stabilization or improvement in functionality, independence, quality of life, coping with disease, nutritional status and wound healing process. In the regular assessments they will be tested for functionality and nutritional parameters, quality of life and stress scores.

Behavioral: Pathfinder support

Control without pathfinder support

NO INTERVENTION

Control patients will not be supported by pathfinders. In regular assessments they will be tested for functionality and nutritional parameters, quality of life and stress scores.

Interventions

Pathfinder support BEHAVIORAL

A pathfinder will support the patient with structured activities.

Pathfinder support

Eligibility Criteria

• Age: 75 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Older Adult (65+)

You may qualify if:

• will go back home after Hospital stay, AOK Patient, MiniMentalStateExamination MMSE score of at least 22, is living within 50 km range of the hospital

You may not qualify if:

• palliative status, planned readmission into hospital within next 4 weeks

Sponsors & Collaborators

• University of Erlangen-Nürnberg Medical School: lead
• Hospital of the Order of St.John of God Regensburg, Barmherzige Brueder, Germany: collaborator
• Regensburg Physicians Network RAEN: collaborator
• Friedrich-Alexander-Universität Erlangen-Nürnberg: collaborator
• AOK Bayern: collaborator
• Institute for Nursing Sciences, University of Bielefeld, Germany: collaborator
• Federal Association for Geriatrics, Germany: collaborator
• Federal Joint Committee: collaborator
• Institute for Community Medicine, University of Greifswald, Germany: collaborator

Study Sites (2)

Hospital of the Order of St.John of God Regensburg

Regensburg, Bavaria, 93049, Germany

Location

Institute for Biomedicine of Aging, University of Erlangen-Nürnberg

Nuremberg, 90408, Germany

Location

Related Publications (2)

• Gehr TJ, Freiberger E, Sieber CC, Engel SA. A typology of caregiving spouses of geriatric patients without dementia: caring, worried, desperate. BMC Geriatr. 2021 Sep 6;21(1):483. doi: 10.1186/s12877-021-02425-1.

  PMID: 34488636 DERIVED

• Rimmele M, Wirth J, Britting S, Gehr T, Hermann M, van den Heuvel D, Kestler A, Koch T, Schoeffski O, Volkert D, Wingenfeld K, Wurm S, Freiberger E, Sieber C; TIGER consortium. Improvement of transitional care from hospital to home for older patients, the TIGER study: protocol of a randomised controlled trial. BMJ Open. 2021 Feb 8;11(2):e037999. doi: 10.1136/bmjopen-2020-037999.

  PMID: 33558344 DERIVED

Study Officials

• Cornel Sieber, Prof. Dr.

  Institute for Biomedicine of Aging

  STUDY DIRECTOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: NONE
• Masking Details: The patients data will be anonymized and entered into an electronic Case Report form. The Outcomes Assessor will only see the anonymized data.
• Purpose: SUPPORTIVE CARE
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Model Details: The Intervention Group will be supported by the activities of the pathfinder, the Control Group will not. Both Groups will be tested for functional and nutritional Status and for Quality of life and stress scores.

Study Record Dates

• First Submitted: April 17, 2018
• First Posted: May 1, 2018
• Study Start: April 25, 2018
• Primary Completion: June 30, 2020
• Study Completion: February 28, 2021
• Last Updated: March 3, 2021

Record last verified: 2021-03

Data Sharing

• IPD Sharing: Will share
• Shared Documents: STUDY PROTOCOL, CSR
• Time Frame: The repository of the data set is under construction with the University.
• Access Criteria: Anonymized data set will be available to interested Researchers upon reasonable request

Locations

DE (2)