AdvantAGE: Implementation and Evaluation of an Interprofessional Tranistional Care Model for Frail Older Adults

NCT06190288 | Recruiting DMC

• 1 other identifier: 02072
• Study Type: interventional
• Target: 250
• Locations: 1 country
• Sites: 1

Brief Summary

This clinical trial at the University Department of Geriatric Medicine FELIX Platter in Basel, Switzerland, is designed to evaluate a new transitional care model aimed at helping frail older adults after they get discharged from the hospital. The AdvantAGE study aims to explore the following questions:

• Does the new care model help reduce the number of patients who need to return to the hospital within 90 days?
• How effective is the implementation of this care model? Participants in the trial will be followed by advanced practice nurses for up to 90 days after hospital discharge. The patients and their caregivers will receive support in coordinating care, managing medications, and learning to manage the patient's health conditions on their own. Additionally, they will have the opportunity to engage in discussions about advanced care planning.

Conditions

Transitional Care; Multimorbidity; Geriatric Care

Keywords

Transitional Care, Frailty, Rehospitalisation, Geratric Care

Outcome Measures

Primary Outcomes (1)

• 90-days rehospitalization rate

  Number of unplanned hospital admissions of any kind happening within 90 days after discharge

  90 days post-discharge

Secondary Outcomes (6)

• 30-days rehospitalization rate

  30 days post-discharge

• Time to readmission

  Up to 90 days post-discharge

• Number of emergency room visits

  90 days post-discharge

• Time to emergency room visit

  Up to 90 days post-discharge

• Patient's health-related quality of life

  Up to 90 days post-discharge

Study Arms (1)

Intervention group

EXPERIMENTAL

The intervention includes five core elements provided by a multiprofessional team: (1) continuous support for patients and caregivers; (2) care coordination with primary care providers;(3) visits at patients' homes; (4) medication- and self-management with patients and caregivers; and (5) proactive advanced care planning. Patients will receive specialized support including home visits up to 90 days after hospital discharge.

Other: Transitional care model

Interventions

Transitional care model OTHER

A newly developed care model to support frail older adults during their transition from hospital to home.

Also known as: AdvantAGE

Intervention group

Eligibility Criteria

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

You may qualify if:

• Currently admitted to the acute or rehabilitation ward of University Department of Geriatric Medicine
• Reside in Basel-Stadt
• Possess the ability to speak and comprehend the German language
• Scheduled to be discharged to their home
• years or older
• Identified by a clinician as having a high risk of deterioration due to frailty
• Additionally, participants must meet at least one of the following criteria:
• diagnosed with a complex chronic disease requiring support in self-management and disease management, or
• facing socially challenging situations such as living alone without a supportive network or lacking a GP, or
• admitted for an acute illness with a brief hospital stay (e.g., infection, cardiac decompensation) and need support in self- and disease management, and continuity of the therapy plan, including close monitoring.

You may not qualify if:

• residing in a nursing home or being newly admitted to one
• lacking informal caregivers and exhibiting severe cognitive impairment (MMS ≤23)
• scoring \<50 on the motoric domain of the Functional Independence Measure (FIM)
• having a psychiatric disorder that significantly impacts their ability to manage daily life at time of the discharge

Sponsors & Collaborators

• Thekla Brunkert: lead
• Health Department of the Canton of Basel-Stadt: collaborator

Study Sites (1)

Universitäre Altersmedizin FELIX PLATTER

Basel, 4055, Switzerland

RECRUITING

Related Publications (1)

• Brunkert T, Pfundstein I, Nickel CH, Lampert ML, Trutschel D, Mauthner O. AdvantAGE: Implementation and Evaluation of an Interprofessional Transitional Care Model for Frail Older Adults-Protocol of an Effectiveness-Implementation Hybrid Study. J Adv Nurs. 2025 Aug;81(8):5130-5142. doi: 10.1111/jan.16745. Epub 2025 Jan 26.

  PMID: 39865439 DERIVED

Related Links

• project homepage (in German)

MeSH Terms

Conditions

Frailty

Interventions

imidacloprid

Condition Hierarchy (Ancestors)

Pathologic Processes; Pathological Conditions, Signs and Symptoms

Study Officials

• Thekla Brunkert, PhD

  Universitäre Altersmedizin FELIX PLATTER

  PRINCIPAL INVESTIGATOR

Central Study Contacts

Mario Ernst

CONTACT

+41 61 326 44 81; mario.ernst@felixplatter.ch

Isabel Pfundstein

CONTACT

+41 61 326 44 81; isabel.pfundstein@felixplatter.ch

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: NA
• Masking: NONE
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: SINGLE GROUP
• Sponsor Type: OTHER
• Responsible Party: SPONSOR INVESTIGATOR
• PI Title: Principle Investigator

Model Details: Hybrid effectiveness-implementation study (type 1)

Study Record Dates

• First Submitted: December 19, 2023
• First Posted: January 5, 2024
• Study Start: January 8, 2024
• Primary Completion (Estimated): June 30, 2026
• Study Completion (Estimated): June 30, 2026
• Last Updated: February 2, 2024

Record last verified: 2024-02

Data Sharing

• IPD Sharing: Will not share

Locations

CH (1)