NCT04796701

Brief Summary

The objective of this study is to evaluate the effect of a transitional care intervention on readmissions among older medical patients. The proportion of older people is rapidly growing. These changes represent a challenge for healthcare systems. 20% of all hospital admitted patients ≥ 65 years are readmitted within the first 30 days after discharge. Prior transitional care research has mainly focused on either hospital-based or community-based interventions with no or little intervention elements in both settings. The results show different effects on readmission rates. This calls for new research on trans-sectorial interventions with both pre- and post-discharge elements.

Trial Health

87
On Track

Trial Health Score

Automated assessment based on enrollment pace, timeline, and geographic reach

Enrollment
1,266

participants targeted

Target at P75+ for not_applicable

Timeline
Completed

Started Feb 2017

Typical duration for not_applicable

Geographic Reach
1 country

1 active site

Status
completed

Health score is calculated from publicly available data and should be used for screening purposes only.

Trial Relationships

Click on a node to explore related trials.

Study Timeline

Key milestones and dates

Study Start

First participant enrolled

February 1, 2017

Completed
2.9 years until next milestone

Primary Completion

Last participant's last visit for primary outcome

December 31, 2019

Completed
Same day until next milestone

Study Completion

Last participant's last visit for all outcomes

December 31, 2019

Completed
1.2 years until next milestone

First Submitted

Initial submission to the registry

February 24, 2021

Completed
19 days until next milestone

First Posted

Study publicly available on registry

March 15, 2021

Completed
Last Updated

November 4, 2021

Status Verified

February 1, 2021

Enrollment Period

2.9 years

First QC Date

February 24, 2021

Last Update Submit

October 27, 2021

Conditions

Frailty

Keywords

readmissiontransitional caredischargeolder medical patients

Outcome Measures

Primary Outcomes (1)

  • Readmission

    Unplanned all-cause readmission

    Readmission will be assessed at 30 days after hospital discharge in both intervention and control group

Secondary Outcomes (1)

  • Mortality

    Mortality will be assessed at 30 days after hospital discharge in both intervention and control group

Study Arms (2)

Follow Home Intervention

EXPERIMENTAL

If possible, all included participants are physically followed home by a hospital-based project worker on the day of discharge. During the visit, the focus is on: basic human needs, medication review reconciliation, and a comprehensive geriatric assessment. Problems, challenges and concerns are discussed. Finally, a conference for the following working day is arranged either as a physical visit or a video conference. The patient, relatives, community-based nurse and project worker are invited to participate and health status and challenges are discussed They are recommended to contact the project worker about health and practical issues up to 7 days after discharge where the intervention ends. Subsequently, the responsibility for treatment and care is assigned to the GP and home healthcare provider.

Other: Follow-Home-intervention

Control

NO INTERVENTION

On the day of discharge, the hospital-based nurse digitally sends a summary of the hospital stay and a treatment and care plan to the community-based nurse. If needed, the hospital-based nurse contacts the community-based nurse by phone as a supplement to the plan. Finally, a discharge letter conducted by the hospital-based doctor is digitally sent to the GP

Interventions

Follow-Home-interventionOTHER

x

Follow Home Intervention

Eligibility Criteria

Age75 Years+
Sexall
Healthy VolunteersNo
Age GroupsOlder Adult (65+)

You may qualify if:

  • Patients aged ≥75 years
  • Living in the municipalities of Odder, Skanderborg, Hedensted or Horsens
  • Admitted for ≥48 hours
  • Discharged from Medical Ward 1 (MSA1) at Horsens Regional Hospital (HRH)

You may not qualify if:

  • Terminally ill patients
  • Patients with cerebrovascular events
  • Readmitted to another hospital
  • Not able to speak and understand Danish

Contact the study team to confirm eligibility.

Sponsors & Collaborators

Study Sites (1)

Horsens Regional Hospital

Horsens, 8700, Denmark

Location

Related Publications (1)

  • Rasmussen LF, Barat I, Riis AH, Gregersen M, Grode L. Effects of a transitional care intervention on readmission among older medical inpatients: a quasi-experimental study. Eur Geriatr Med. 2023 Feb;14(1):131-144. doi: 10.1007/s41999-022-00730-5. Epub 2022 Dec 23.

    PMID: 36564644DERIVED

MeSH Terms

Conditions

Frailty

Condition Hierarchy (Ancestors)

Pathologic ProcessesPathological Conditions, Signs and Symptoms

Study Officials

  • Merete Gregersen, PHD

    Aarhus University Hospital

    STUDY CHAIR

Study Design

Study Type
interventional
Phase
not applicable
Allocation
NON RANDOMIZED
Masking
NONE
Masking Details
Intervention group: living in three predefined municipality Control group: living in one predefined municipality
Purpose
PREVENTION
Intervention Model
PARALLEL
Model Details: Non-randomized controlled trial
Sponsor Type
OTHER
Responsible Party
SPONSOR

Study Record Dates

First Submitted

February 24, 2021

First Posted

March 15, 2021

Study Start

February 1, 2017

Primary Completion

December 31, 2019

Study Completion

December 31, 2019

Last Updated

November 4, 2021

Record last verified: 2021-02

Data Sharing

IPD Sharing
Will not share

Locations

DK(1)