Bridging the Gap: Creating a Continuum of Care

NCT06368674 | Recruiting

• 1 other identifier: 2023-00363
• Study Type: interventional
• Target: 150
• Locations: 1 country
• Sites: 1

Brief Summary

Coordination and integration between care settings is essential for the quality of care of frail older patients. An active follow-up by a case manager (CM) after discharge form an acute geriatric hospital ward has the potential to bridge the gap between hospital, primary and municipality care for frail older people. This study evaluates the effects of an active follow-up by a CM in primary care after discharge from a geriatric ward, with the following research questions: Can an active follow-up by CM for frail older people discharged from an acute geriatric ward, compared to those not receiving active follow up, Maintain/increase independence in activities of daily living, self-rated health and life satisfaction? Increase satisfaction with health care? Reduce health care consumption/be cost-effective? How feasible is the intervention and the study design from the perspective of the caregivers and the older person? This is a clinical controlled study with a process evaluation. Inclusion criteria are 75 years or older, frail and admitted to a geriatric ward. This study is relevant since today's highly specialized acute care is poorly adapted to the comprehensive needs of frail older people, and exposes them to avoidable risks such as loss of functional capacities causing unnecessary care needs and decreased wellbeing. Active follow-up by a CM after discharge may be an important way to integrate the care for frail older people, after receiving in-hospital geriatric care. This can improve the quality of care for this vulnerable group, and direct the right health care actions towards those in most need. The intervention is a active follow-up after discharge by a CM (nurse) in primary care. CM will secure that discharge and care plans are executed and to address new needs. If there are unmet needs, the CM will ensure that adequate actions are performed to meet the needs. The intervention group consists of participants discharged to a primary health care centre with a CM, who actively follows-up after discharge. The control group consists of participants discharged to a primary health care centre without CM, and thereby no active follow-up after discharge. All participants will be followed-up by the research team during one year, concerning dependence in activities of daily living, self-rated health, health care consumption and satisfaction with care.

Conditions

Frailty; Dependence; Integrated Care

Keywords

Person-centred care

Outcome Measures

Primary Outcomes (1)

• Dependency in Activities of Daily Living (ADL)

  The primary outcome, dependence in activities of daily living, is measured using the ADL-staircase assessment. It measures dependence in 9 activities: cleaning, shopping, transportation, cooking, bathing, dressing, going to the toilet, transferring, and feeding. Dependence is defined as a state in which another person is involved in the activity by giving personal or directive assistance. The sum of dependence in the nine activities of daily living will be calculated, range 0-9, with a clinical significant change of ≥1 unit between baseline and follow up.

  Baseline to 12 months

Secondary Outcomes (4)

• Self-rated health

  Baseline to 12 months

• Life satisfaction

  Baseline to 12 months

• Satisfaction with quality of care

  Baseline to 12 months

• Health economics

  12 months

Study Arms (2)

Intervention group Case Manager (CM)

EXPERIMENTAL

The intervention group will receive extra follow-up by a CM after discharge.

Other: Intervention group Case Manager (CM)

Control group

OTHER

The control group will receive usual follow-up after discharge, i.e. no active follow-up

Other: Control Group

Interventions

Intervention group Case Manager (CM) OTHER

The CM will be informed about the discharge plan from the nurse at the geriatric ward, as will the municipality for those with need of home help care. An outline of the intervention has been created with managers from primary care and rehabilitation within primary care and municipality care. Core components in the intervention will be active follow-up of the discharge, rehabilitation and care plans. If there are plans that have not been executed or unmet needs, the CM will take adequate contacts to ensure that actions are made to meet the needs. These contacts can be, e.g. the GP for medical needs, the rehabilitation unit in primary or municipality care for unmet rehabilitation needs, and the home help service for unmet care needs. The CM will have a network of contact persons in hospital, primary and community care, as well as in rehabilitation in primary and community care, in order to facilitate for prompt actions to meet the needs.

Intervention group Case Manager (CM)

Control Group OTHER

The participants in the control group with a planned follow-up by a primary health care centre within the catchment area of the Sahlgrenska University Hospital that does not have CMs designated for active follow up of discharged frail older people. Thus, the participants in the control group will not actively be followed-up after discharge.

Control group

Eligibility Criteria

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

You may not qualify if:

• Less that 75 years old, Not residing in a permanent residence.

Sponsors & Collaborators

• Göteborg University: lead
• Vastra Gotaland Region: collaborator
• Sahlgrenska University Hospital: collaborator
• Forte: collaborator

Study Sites (1)

University of Gothenburg

Gothenburg, Sweden

RECRUITING

MeSH Terms

Conditions

Frailty

Interventions

Control Groups

Condition Hierarchy (Ancestors)

Pathologic Processes; Pathological Conditions, Signs and Symptoms

Intervention Hierarchy (Ancestors)

Epidemiologic Research Design; Epidemiologic Methods; Investigative Techniques; Research Design; Methods

Central Study Contacts

Theresa Westgård, PhD, Associate Professor

CONTACT

18628820334; Theresa.westgard@neuro.gu.se

Isabelle Andersson Hammar, PhD, Associate Professor

CONTACT

+46766185719; Isabelle.a-h@neuro.gu.se

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: NON RANDOMIZED
• Masking: SINGLE
• Who Masked: OUTCOMES ASSESSOR
• Purpose: SUPPORTIVE CARE
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Model Details: Clinical control study

Study Record Dates

• First Submitted: April 11, 2024
• First Posted: April 16, 2024
• Study Start: June 6, 2024
• Primary Completion (Estimated): December 31, 2026
• Study Completion (Estimated): February 1, 2027
• Last Updated: April 11, 2025

Record last verified: 2025-04

Locations

SE (1)