Evaluation of Community-based Care for the Frail Elderly

NCT03768050 | Unknown DMC

• 1 other identifier: SELFIE-BSA
• Study Type: interventional
• Target: 500
• Locations: 1 country
• Sites: 1

Brief Summary

The term frail chronic complex patient (CCP) is generally applied to subjects with heterogeneous conditions that may represent at least one of the following three traits: (i) the need for management by a number of specialists from different disciplines that often leads to high use of healthcare resources; (ii) fragility, which requires additional support either due to functional decline, social deficits and/or transient situations such as hospital discharge or, (iii) the need for highly specialised care with home technological support. The current protocol deals with the second category of patients, frail CCP, and addresses horizontal integration of community-based services. It is based in the city of Badalona (216K inhabitants), within the metropolitan area of Barcelona. Badalona Serveis Assistencials (BSA) is the service provider of integrated care services for this population.

Conditions

Chronic Disease; Frail Elderly Syndrome

Keywords

integrated care

Outcome Measures

Primary Outcomes (1)

• Costs

  Health Care Costs

  30 days

Secondary Outcomes (3)

• Number of hospital admissions

  30 days

• Patient centred healthcare provision

  30 days

• Continuity of care within the healthcare system

  30 days

Study Arms (2)

Advanced care for frail elderly

ACTIVE COMPARATOR

Integrated care program for frail elderly covering Home Hospitalization/Early Discharge; geriatric residences and; home-based case management done by dedicated teams specialised in geriatric medicine

Other: Advanced care for frail elderly

Standard care

NO INTERVENTION

Usual care at the community and geriatric residences by primary care physicians

Interventions

Advanced care for frail elderly OTHER

Home-based case management group receives advanced nursing care meeting the health and social needs of patient and/or carer. It is carried out through a process of evaluation, planning\&coordination, facilitating the provision, monitoring and evaluation of the options and resources necessary for the resolution of the case. It is person-centred. The service also provides palliative care. Home hospitalisation/early discharge dispenses medical and nursing care at home on a transient basis after hospitalisation when patients still need surveillance and assistance. It is done in the acute, subacute or post-acute phase. In the last phase the focus is on functional recovery. The geriatric residences group is assisted by health care teams with expertise in geriatrics. They coordinate with primary care and health professionals of the residences to improve the attention. They are highly accessible, have high-resolutive capacity and can activate the resources of the healthcare network.

Advanced care for frail elderly

Eligibility Criteria

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

You may qualify if:

• Age ≥ 65 years.
• Complexity: ≥ 2 chronic diseases
• Polypharmacy: ≥ 4 drugs
• Registered as complex chronic patient
• ≥ 3 hospital or emergency room readmissions in the last year
• Having suffered a recent acute illness requiring continuous clinical and/or rehabilitative care by the Home Hospitalisation Unit or primary care.
• To be admitted in one of the geriatric residences of the territory of Badalona, Montgat and Tiana.

You may not qualify if:

• Any neurological disease (e.g. severe-phase dementia with global deterioration scale (GDS) ≥ 7) or psychiatrically severe enough not to allow the subject to respond to questionnaires.
• Subjects who do not agree to participate in the study.

Sponsors & Collaborators

• Hospital Clinic of Barcelona: lead

Study Sites (1)

Hospital Clinic

Barcelona, Catalonia, 08036, Spain

RECRUITING

Related Links

• NEXTCARE is an innovation project belonging to the Healthcare Ris3Cat community lead by Biocat which officially starts on October 2016
• SELFIE (Sustainable intEgrated care modeLs for multi-morbidity: delivery, FInancing and performancE) is a Horizon2020 European Union project

MeSH Terms

Conditions

Chronic Disease

Condition Hierarchy (Ancestors)

Disease Attributes; Pathologic Processes; Pathological Conditions, Signs and Symptoms

Study Officials

• Josep Roca, MD

  Hospital Clinic

  PRINCIPAL INVESTIGATOR

Central Study Contacts

Jordi Piera, PhD

CONTACT

+34932275747; jpiera@bsa.cat

Josep Roca, MD

CONTACT

+34932275747; jroca@clinic.cat

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: NON RANDOMIZED
• Masking: NONE
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Consultor Senior

Study Record Dates

• First Submitted: November 28, 2018
• First Posted: December 7, 2018
• Study Start: April 1, 2018
• Primary Completion: March 1, 2019
• Study Completion: April 1, 2019
• Last Updated: December 7, 2018

Record last verified: 2018-12

Data Sharing

• IPD Sharing: Will not share

Locations

ES (1)