Models of Care in the Transition From the Secondary to the Primary Sector Among the Frailest Elderly

NCT03796923 | Completed DMC

• 1 other identifier: MOCATRANFRAELRCT
• Study Type: interventional
• Target: 3,340
• Locations: 1 country
• Sites: 1

Brief Summary

In most Western countries the elderly population increases rapidly. In Denmark, the population of elderly aged 75 years or older may amount to nearly 15 % of the entire population in 2050 compared to 9 % today (2017). A large part of the elderly population is at high risk of hospitalization including more admissions and increased morbidity and mortality. The number of hospital beds is declining persistently, calling for shorter lengths of stay (LOS). Increasingly complex treatments now take place outside hospital. Presently, many Danish regional hospitals establish geriatric wards and other geriatric in-hospital and outpatient services to overcome these challenges. The aim of the present PhD-study is to investigate the effects of different models of transitional care among the frailest elderly patients.

Conditions

Frail Elderly Syndrome; Transitional Care; Frailty; Readmission; Aging; Elderly

Keywords

Elderly; Hospital at home; Readmission; Transitional care; Frailty; Patient Related Outcome Measures

Outcome Measures

Primary Outcomes (1)

• Readmission

  Readmission within 30 days after discharge

  30 days

Secondary Outcomes (2)

• Mortality

  90 days after admission and 30 days after primary discharge

• Length of stay (LOS)

  30 days after primary discharge

Other Outcomes (4)

• Physical functional status 30 days after discharge

  30 days after discharge

• Duration of readmission

  30 days after discharge

• Time at home before readmission

  30 days after discharge

Study Arms (3)

Intervention I

ACTIVE COMPARATOR

Intervention (I): early follow-up visit from the community nurse within 24 hours after discharge

Other: Early follow-up visit after discharge; Other: Comprehensive geriatric assessment (CGA)

Intervention II

EXPERIMENTAL

Intervention (II): early follow-up by the geriatric team within 24 hours after discharge

Other: Early follow-up visit after discharge; Other: Comprehensive geriatric assessment (CGA); Other: Continued geriatric care

Control

OTHER

Usual care: individualized follow-up performed by the GP and municipality services

Other: Possible follow-up visit from GP

Interventions

Early follow-up visit after discharge OTHER

Early follow-up visit and different degrees of specialized care after discharge

Intervention I; Intervention II

Comprehensive geriatric assessment (CGA) OTHER

Comprehensive geriatric assessment (CGA) during admission

Intervention I; Intervention II

Continued geriatric care OTHER

Continued specialized geriatric care after discharge

Intervention II

Possible follow-up visit from GP OTHER

Usual care: follow up visit from GP within one week after discharge

Control

Eligibility Criteria

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

You may qualify if:

• Aged 75 years or older
• Living within the municipality of Aarhus (except for the control group, see below)
• MPI-score = 2 (moderate frailty) or MPI score = 3 (severe frailty)

You may not qualify if:

• Included in any other kind of follow-up schemes
• Declared terminally ill or undergoing palliative care at admission
• Admitted from one specific temporary nursing home with geriatric medical assistance
• Discharge or transfer to another department, including hospice
• MPI-score = 1 (low frailty)
• Discharged to one specific temporary nursing home with geriatric medical assistance
• The patient does not want a visit after discharge

Sponsors & Collaborators

• University of Aarhus: lead

Study Sites (1)

Aarhus University

Aarhus, Denmark

Location

Related Publications (1)

• Hansen TK, Pedersen LH, Shahla S, Damsgaard EM, Bruun JM, Gregersen M. Effects of a new early municipality-based versus a geriatric team-based transitional care intervention on readmission and mortality among frail older patients - a randomised controlled trial. Arch Gerontol Geriatr. 2021 Nov-Dec;97:104511. doi: 10.1016/j.archger.2021.104511. Epub 2021 Aug 26.

  PMID: 34479071 DERIVED

MeSH Terms

Conditions

Frailty

Interventions

Geriatric Assessment

Condition Hierarchy (Ancestors)

Pathologic Processes; Pathological Conditions, Signs and Symptoms

Intervention Hierarchy (Ancestors)

Data Collection; Epidemiologic Methods; Investigative Techniques; Health Status; Demography; Population Characteristics; Health Care Evaluation Mechanisms; Quality of Health Care; Health Care Quality, Access, and Evaluation; Epidemiologic Measurements; Public Health; Environment and Public Health

Study Officials

• Else Marie S Damsgaard, Prof., DMSci

  University of Aarhus

  STUDY CHAIR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: NONE
• Purpose: SUPPORTIVE CARE
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: January 2, 2019
• First Posted: January 8, 2019
• Study Start: January 1, 2018
• Primary Completion: September 16, 2020
• Study Completion: November 16, 2020
• Last Updated: April 30, 2021

Record last verified: 2021-04

Locations

DK (1)