Models of Care in the Transition From the Secondary to the Primary Sector Among the Frailest Elderly +75; a Randomized Controlled Trial
Phase: NA
Conditions: Frail Elderly Syndrome, Transitional Care, Frailty, Readmission, Aging, Elderly
Sponsor: University of Aarhus

 
 
Models of Care in 
the Transition from 
the Secondary to 
the Primary Sector 
among the Frailest 
Elderly +75; a 
Randomized 
Controlled Trial 
 
 
 
 
 
 
 
Troels Kjærskov Hansen 
 
Aarhus University Hospital 
 
Randers Regional Hospital 
 
Aarhus University 
 
February 8th, 2019 
 
 
 
Models of Care in the Transition from the Secondary to the Primary Sector among the Frailest Elderly +75; a Randomized Controlled Trial 
 
 
 
 
 

Models of Care in the Transition from the Secondary to the 
Primary Sector among the Frailest Elderly +75; a Randomized 
Controlled Trial 
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) (1). A large part of 
the elderly population is at high risk of hospitalization including more admissions and increased morbidity and mortality 
(2,3). The number of hospital beds is declining persistently (4), calling for shorter lengths of stay (LOS) (5,6). 
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. 
 
Readmission 
 
Readmitted patients occupy many beds and other hospital resources. Patients are at a risk of high mortality (7) and 
decline of functional ability (8,9). More than 20 % of Danish medical patients aged 65 years or older become readmitted 
within 30 days after discharge (10), more frequently in the frail elderly (11). The risk of readmission is particularly high 
within the first week after discharge, where more than 40% of readmissions happen (12,13). Many reasons and factors for 
readmissions have been mentioned (11,14-16) such as: former or recent admission, duration of the index hospitalization, 
degree of comorbidity and low functional ability (11,15). To prevent readmissions it is important to identify the reason 
for admission and remove it, to ensure that the correct medication is implemented and make sure that adequate social 
service is provided, to convey unsolved problems to the primary care, ensure continuity during transfer and finally 
establish sufficient and timely follow-up after discharge (11,14-17). 
 
Identification of patients at risk 
 
Many factors leading to readmission and other adverse events are related to frailty (11,15,18). Prevention of adverse 
events has traditionally relied on clinicians' and caregivers' ability to anticipate the needs and requirements after 
discharge. Comprehensive Geriatric Assessment (CGA) is considered as the gold standard to detect frailty (19). To make 
this easier tools to determine frailty have been developed. In the present study the Multidimensional Prognostic Index 
(MPI; see Appendix 1A and 1B (slightly adjusted Danish version)) has been chosen to determine the level of frailty. MPI 
is fully applicable in the everyday clinical work and supplies useful information to clinicians, it is validated in a Danish 
context, predicts readmission and death (20), and is well-suited to assess the degree of frailty (18,21). 
 
Usual care 
 
Present usual care in Denmark with regard to discharge and transfer, consists of discharge planning. It relies largely on 
the GP's follow-up visits (see Appendix 2). This approach reduces readmission (22), but the use is limited due to poor 
implementation, lack of referral, and missing follow-up despite referral (23,24). Only a minor fraction of the frail 
receives a follow-up visit within the first week after discharge. The GP-based intervention is presently subject to 
discussion (23,24). Urgent or hospital-at-home-like treatment is needed to avoid readmission. This requires of a well-
informed round the clock service. The urgency of follow-up of the frail elderly does not fit into the scheme-based 
workday of the GP and the on-call GP system. In some districts, additional specialized geriatric wards and outgoing 
teams exist, but the capacity and contents of these units are limited and vary. Community nurses might after some 
reorganization hold an untapped potential to improve transition. 
 
Counteractions to readmission 
 
Even though all possible precautions are made before discharge, readmissions still occur. They are often preceded by a 
series of events stressing the need for multifaceted care and intersectoral efforts in relation to discharge. Many 
approaches are already applied: 
 

To avoid obvious and predictable events leading to readmission, comprehensive discharge planning has been 
introduced in many different countries, probably reducing readmission and LOS without increasing mortality 
(25,26). 

In a Danish context discharge follow-up is largely based on GP-conducted visits within one week after discharge 
and offered to a fraction of the elderly. 

Multiple discharge support arrangements have been tested ranging from isolated follow-up telephone calls by a 
hospital nurse to highly specialized multidisciplinary geriatric teams doing home visits. Early follow-up visits 
by community nurses have been tested showing possible effect on mortality but not on readmissions (27). 
Another recent randomized clinical trial (RCT) reports considerable positive effect on readmission, LOS and 
direct discharge from the ED (12), while a second RCT performed in the same population shows a reduction of 
 
 
Models of Care in the Transition from the Secondary to the Primary Sector among the Frailest Elderly +75; a Randomized Controlled Trial 
 
 
 
 
 

mortality among patients living in their own homes (7). The study shows considerable effect of early team-based 
home visits applied on selected elderly at high risk of readmission (12). 

Comprehensive Geriatric Assessment (CGA) provides an individualized, multidisciplinary and intersectoral 
approach when applied by geriatricians in inpatient geriatric wards and in Emergency Departments (ED) and 
outpatient clinics, in order to improve outcomes of hospitalization. The effects of CGA on readmission, length 
of stay (LOS) or mortality has yet not been well-proven. It reduces medication and increases the probability of 
discharge at home (25,28). The effect of CGA combined with an early geriatric home visit has resulted in a 
significant reduction of the readmission rate within 30 days when compared to the GP-conducted follow-up 
visits after a week (12). 
 
Outcome measures 
 
According to the various interventions stated above, the outcomes of relevance are readmissions (8-12,15,17,22,24-
26,28-44), mortality (7,8,10,12,25,27,28,30-32,38-41,44), length of stay (LOS) (12,25,28,29,32,38,41,45), direct 
discharge from the ED (12,29), time at home (10,25,27,34), duration of readmission (10,25,34) and physical functional 
status (8,25,27,28,30,31,34,40,43-45). A successful intervention may be reflected in a shorter LOS, lower risk of 
readmissions, longer time at home, maintained functional status and a shorter duration of readmission. We suggest that a 
significant and effective intervention under the best circumstances is reflected in these outcomes. Readmissions are 
usually considered as such, when the admission occurs within 4 hours after and before 30 days after discharge. Among 
the frail, in-hospital and post-discharge mortality is high, needing frequent assessment. As shown by Pedersen et al. (7), 
mortality differs with regard to type of dwelling. Former studies have shown a significant and remarkable reduction of 
LOS (reduction from median 3 days to median 2 days) and an increase from 49 % to 56 % of patients discharged directly 
from the ED due to the possibility of early follow up by a geriatric team (12). Functional status is of relevance, especially 
combined with mortality data, since a better survival of the frailest may be combined with a worsened functional status in 
the total group. Patient Related Outcome Measures (PROMs) will be assessed and added as secondary outcomes during 
the project. Patient satisfaction and costs are other relevant outcome measures with regards to the triple aim principle, but 
will not be included in the present Ph.D. project. 
 
Conclusion 
 
While some previously tested interventions, including CGA and discharge support arrangements, have been futile 
(25,31,46), we believe that multidisciplinary, tailored interventions used in selected high-risk groups throughout 
hospitalization and discharge are effective (8,12,29,34,44). Most former studies regarding early follow-up visits and 
CGA are made in geriatric settings, somewhat distanced to usual care and municipality services. Many previous trials 
have included patients without looking in particular for frail high-risk patients, thereby probably underestimating the 
effects of the intervention. It is not known if an early visit by a community nurse would have the same effect as an early 
geriatric home visit. Selection of elderly patients who will benefit from home visits by a geriatric team after discharge 
compared with a community nurse visit or usual care may be useful. MPI has been able to predict mortality, LOS (47), 
and readmissions (48), but has not previously been tested as a selection tool to distinguish between different follow-up 
methods. It has been suggested that the major effect from early follow-up is more or less independent of the type of 
follow-up, but is caused by the early visit itself. The type of dwelling may influence the effect of an early visit, since the 
care setup in some nursing homes may resemble that of a hospital. The level of frailty may influence the effectiveness 
and efficacy of the different follow-up schemes. Some patients may be chronically frail and their frailty may already have 
been handled prior to admission, in a way that dilutes the effect of early follow-up visits. The length of stay and other 
secondary endpoints may rely largely on the planned follow-up approach. The level of frailty predicts the risk of 
readmission and mortality and can therefore be used as a major indicator when clinicians have to choose between 
different follow-up approaches. 
 
Objectives 
The aim of this study is to investigate the effects of two interventions using CGA and early post-discharge follow-up 
visits in a population of frail 75+ year-olds compared to usual care. The vision is to find feasible and durable approaches 
that can improve patient outcome in the transition from hospital to primary health care. We are aiming to identify 
subjects who will profit the most from each approach. 
 
All frail patients admitted to the ED and the Department of Geriatrics are randomized 1:1 to one of two different follow-
up efforts prior to CGA performed during hospitalization. Thereby the intervention is randomly split into two groups: 
 

An intervention (I) consisting of CGA during hospitalization and early post-discharge follow-up care by a 
community nurse and a GP 

An intervention (II) consisting of CGA during hospitalization and early post-discharge follow-up care, including 
continued CGA and tailored follow-up care, by a geriatric team 
 
 
Models of Care in the Transition from the Secondary to the Primary Sector among the Frailest Elderly +75; a Randomized Controlled Trial 
 
 
 
 
 

The intervention cohort will be compared to a control cohort consisting of similar frail elderly who receive usual care 
without involvement of geriatric care during hospitalization and after discharge. 
 
Hypotheses 

The geriatric team follow-up is as effective as a community nurse and GP follow-up measured by readmission, 
mortality, LOS, direct discharge from ED and physical functional recovery 

The effects of three transitional follow-up approaches (community nurse and GP; multidisciplinary geriatric 
team; usual care) are similar measured in terms of readmission, time at home, duration of readmission, LOS, 
direct discharge from ED, mortality and PROMs 

When stratified into subgroups with regards to level of frailty (moderate and severe) and type of dwelling, the 
geriatric team follow up is as good as community nurse and GP follow-up measured by readmission, mortality, 
LOS, direct discharge from ED and physical functional recovery 
 
 
Methods 
Design 
 
The first study is conducted as a randomized controlled trial (RCT) using two different degrees of intervention. The 
second study is a cohort study where the two groups in the RCT are compared to an unexposed control group. The third 
study is sub-group analyses of the RCT data according to frailty status and type of dwelling. 
 
Study population 
 
The population allocated to intervention comprises geriatric patients acutely admitted to the ED, Aarhus University 
Hospital (AUH) or transferred to one of the two geriatric wards at AUH. Subjects are included immediately on the day of 
admission at the ED, AUH and the Department of Geriatrics (wards 1 and 2), AUH, as shown in Fig. 1. Patients admitted 
to the ED at night and promptly discharged before enrollment to the intervention cohort can be performed the following 
day are not included. Likewise, patients to the control group are included immediately on the day of admission at the ED, 
Randers Regional Hospital (RRH), and at the medical wards 1, 2, 3 and 4, RRH. Patients transferred to other departments 
are excluded. Patients can only be included once. Enrollment and randomization to the intervention group are performed 
by therapists working in the ED or the geriatric wards. Enrollment to the control group is done by a Research Assistant. 
In the control group frailty screening is done by the PhD-student using a frailty screening tool based exclusively on data 
collected through medical records. The frailty screening tool will be validated by crosschecks performed by a blinded 
project Research Assistant. The results of the validation study will be analyzed and published during 2019. 
 
Inclusion criteria: 
 

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) 
 
Exclusion criteria: 
 

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 (Vikærgården) 

Discharge or transfer to another department, including hospice 

MPI-score = 1 (low frailty) 

Discharged to one specific temporary nursing home with geriatric medical assistance (Vikærgården) 

The patient does not want a visit after discharge 
 
Inclusion- and exclusion criteria to the control group are the same as for the two intervention groups, except that subjects 
eligible for the control group are living within the four municipalities of RRH: Randers, Favrskov, Norddjurs and 
Syddjurs. 
 
Randomization 
 
As shown in Fig. 2, all intervention group patients are allocated at the time of randomization on the day of admission to 
receive either early visit from the community nurse (I) or the multidisciplinary geriatric team (II). The randomization is 
stratified with regard to dwelling (living alone; cohabiting; nursing home) and number of drugs prescribed prior to 
 
 
 
Models of Care in the Transition from the Secondary to the Primary Sector among the Frailest Elderly +75; a Randomized Controlled Trial 
 
 
 
 

admission (0-3, 4-7, 8 or more drugs), and conducted using the randomization function in REDCap (49). Randomization 
is open throughout the whole admission with the purpose to enable early discharge planning. 
 
Intervention I and II 
 
Both intervention groups are assessed according to CGA, either by the geriatrician and the physiotherapist/geriatric nurse 
in the ED, or by a multidisciplinary team comprised of geriatricians, specialized nurses, physiotherapists and 
occupational therapists during hospitalization in the geriatric wards. 
 

Intervention (I): comprises early follow-up visit from the community nurse within 24 hours after discharge, and 
the possibility of consulting a nutritionist, thus supplementing usual care services including the possibility of 
consulting the patients' GP. Responsibility of treatment including implementation of suggested initiatives and 
any further assessment is handed over to the GP at discharge. 

Intervention (II): CGA is continued during early follow-up by the geriatric team. On weekdays visits are 
scheduled within 24 hours after discharge. For patients discharged during weekends or holidays, supporting 
telephone calls are provided by the geriatric team. If needed, the geriatric team nurse visits the patient. The 
concept of CGA in this stage does not differ from the above-mentioned. There are no standardized demands, but 
a part of the intervention can be to perform hospital services at home and continued treatment and diagnostics 
after discharge. The possible services provided by the geriatric team are further described in the geriatric team 
course description. The responsibility of treatment rests with the geriatric team until dispatch of the discharge 
summary. Patients then return to usual care. The geriatric team follow-up is planned to last a maximum of 7 
days, yet allowing extension for as long as there is a need for services performed exclusively by the geriatric 
team as described in the geriatric team course description. 
 
Control group 
 
The patients in the control group are discharged to usual care and do not receive early follow-up visits. Usual care 
features municipality services and optionally a GP home visit (see Appendix 2). Eligible control patients are 
consecutively included by a Research Assistant. The estimated level of frailty will be assessed by the PhD-student based 
on a MPI-screening tool fitted to be performed using only medical record data. This fitted tool will be tested and 
validated prior to the inclusion of the control group. Clinicians will be blinded to the result of the MPI-screening of the 
control subjects to ensure that discharge is performed in accordance with usual care. 
 
Outcomes 
The primary outcome is readmission within 30 days after discharge. Secondary outcomes are: 
 

Mortality 30 days after discharge and 90 days after admission 

Length of stay during primary admission and total length of stay including following readmissions 

Direct discharge from the Emergency Department 

Time at home before readmission 

Duration of readmission 

Physical functional status 30 days after discharge (Functional Recovery Score) 

Patient Related Outcome Measures as defined by a focus group of included patients and/or their relatives 
 
Statistical analyses 
Data are registered in REDCap and exported to STATA version 15 for the statistical analyses. Statistical significant 
results are defined as a p-value of 5% or less. The two intervention groups and the control group will be compared with 
regard to baseline measures. If needed, statistical corrections for demographical differences and level of frailty will be 
made. The use of services and other contents of follow-up will be assessed and compared if possible. Baseline data 
collected for the entire study population before discharge are: age, gender, date of admission, co-habitation status, 
number of drugs, and level of frailty measured by MPI including functional status by means of Functional Recovery 
Score (FRS) at discharge. Follow-up data for the control group will be collected on type of planned care after discharge. 
Follow-up data for the entire study population will be collected on: department of discharge, date of discharge, primary 
diagnosis at discharge, dwelling after discharge, readmission date, and death date. For the intervention cohort additional 
data are collected: date of follow-up, provided services after discharge, number and date of visits (team, GP, nurse) after 
discharge, phone-calls to the geriatric team or GP, nutritionist consultations, FRS after 30 days, date of dispatch of 
discharge summary. Additional data will be collected by review of the electronic patient records. 
 
 
 
 
 
 
Models of Care in the Transition from the Secondary to the Primary Sector among the Frailest Elderly +75; a Randomized Controlled Trial 
 
 
 
 
 

 
Outcomes 
 
A hazard ratio (HR) for readmissions will be calculated using a Cox regression model with death as a 'competing risk' 
factor. The HRs of readmission with 95% confidence intervals (95% CI) for interventions I and II will be compared 
individually and to the control group. The interventions will be tested in subgroup analyzes based on: patients discharged 
directly from the ED, type of dwelling and level of frailty. Median LOS, time at home before readmission and duration of 
readmission will be calculated and compared using the Wilcoxon rank-sum test. The mortality hazard ratio will be 
calculated also using the Cox regression model. The change in functional status at discharge and 30 days after discharge 
will be compared in a linear regression model. Data will be analyzed in accordance with intention-to-treat and per-
protocol analysis. 
 
Sample size 
 
Power analysis is based on a pilot study performed from June to December 2017 using the method stated above, and 
earlier studies by Pedersen et al.(7,12), where patients selected by diagnoses associated with readmission were 
randomized to early geriatric follow-up visits or usual care. Readmissions were reduced from 23% to 12%. Data 
collected during the pilot study showed 13.7% readmissions in the Intervention group I compared to 8% readmissions in 
the Intervention group II. Based on the pilot study data, allowing a 5% drop-out rate and a 30-day mortality rate of 10%, 
the number of patients in each trial arm should be 758 in order to achieve a power of 90% and a level of significance of 
5%. Data collected during the same pilot study showed a 90-day mortality rate of 20.6% in Intervention group I 
compared to 15.6 % in Intervention group II. To achieve a power of 80% and a level of significance of 5% with regards 
to mortality, the sample size of each arm should be 1,019, including a 5% drop-out rate. 
 
Perspectives 
This study may uncover a need for specialized and early efforts to support transfer of the frail elderly. We may find that 
some of the frail elderly are poorly supported by the present follow-up procedures, suggesting that comprehensive 
geriatric assessment and early follow-up intervention by a community nurse and a geriatric team should gain further 
currency in the future. This study may contribute to dimension health care services in the future. We hope to clarify the 
possible need for geriatric services outside university hospitals. The results are directly transferable to Danish regional 
hospitals and may be of importance in other Western countries. 
 
Ethics 
The study has been approved as a quality development project by the Regional Research Ethics Committee, Central 
Denmark Region (journal no. 197/2017), thereby no patient consent form is needed, and further referral to the committee 
not required. No patient will receive less than usual care, no extra treatment or examination will be applied, and no 
patient will be exposed to any additional risk because of the project. Participants may decline parts of or the entire 
intervention, including usual care, at any time. The project, which is a part of the national rate adjustment pool-project 
"Early post-discharge follow-up of the frail elderly – a intersectoral effort" in the Central Denmark Region, is approved 
by the Danish Data Protection Agency (journal no. 2012-58-006). 
 
Organization and economy 
The project is embedded in the Geriatric Department, Aarhus University Hospital. The project is conducted in 
cooperation with Aarhus Municipality, represented by health consultant, PhD, Monica Milter Ehlers, and Randers 
Regional Hospital, where professor, MD, PhD, Jens Meldgaard Bruun and MD, geriatric specialist, Seham Shahla will be 
co-supervisors. See Fig. 3. The Project Manager, MD, PhD-student Troels Kjærskov Hansen, will be employed at both 
hospitals as a clinical assistant. The day-to-day work will take place mainly in the Research Unit at the Geriatric 
Department, AUH under supervision of the main supervisor, professor, MD, PhD, Else Marie Damsgaard, and co-
supervisor, clinical specialist, PhD, Merete Gregersen. Through the Geriatric Department, AUH, there will be available 
statistical expertise attached to the project. Data regarding the intervention group will be collected by the research 
assistants associated to the Geriatric Department, AUH with regard to the frailty screening and baseline characteristics. 
Functional status at follow-up will be assessed by Aarhus municipality research assistants. The three months’ leave for 
writing the project protocol was sponsored by the Central Denmark Region's Health Research Foundation. Follow-up as 
well as the hospital and municipality research assistants are partly funded by the Rate Adjustment Pool, the Geriatric 
Department, AUH, and Aarhus Municipality. Future expenses will be PhD student salary, Study Fee, wage for a research 
assistant, costs of courses, congresses, transportation, and publication. 
 
My part 
The Project Manager is admitted to the PhD programme and PhD courses at Aarhus University. The PhD-student is 
responsible for the collection, storage, analysis and correctness of all data. The PhD-student will apply for the remaining 
funding and publish and present the data from the project in relevant peer-reviewed journals and at national and 
international congresses. The project is reported to ClinicalTrials.gov. Research Plan: see Appendix 3. 
 
Models of Care in the Transition from the Secondary to the Primary Sector among the Frailest Elderly +75; a Randomized Controlled Trial 
 
 
 
 

 
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for older adults admitted to hospital. Cochrane Database Syst Rev 2017 2017/09;2017(9). 
 
 
(29) Conroy SP, Ansari K, Williams M, Laithwaite E, Teasdale B, Dawson J, et al. A controlled evaluation of 
comprehensive geriatric assessment in the emergency department: The 'Emergency Frailty Unit'. Age Ageing 2014 
/;43(1):109-114. 
 
 
(30) Kircher TTJ, Wormstall H, Müller PH, Schwärzler F, Buchkremer G, Wild K, et al. A randomised trial of a geriatric 
evaluation and management consultation services in frail hospitalised patients. Age Ageing 2007 /;36(1):36-42. 
 
 
(31) Conroy SP, Stevens T, Parker SG, Gladman JRF. A systematic review of comprehensive geriatric assessment to 
improve outcomes for frail older people being rapidly discharged from acute hospital: 'Interface geriatrics'. Age Ageing 
2011 /;40(4):436-443. 
 
 
(32) Gregersen M, Pedersen ABL, Damsgaard EM. Comprehensive geriatric assessment increases 30-day survival in the 
aged acute medical inpatients. Dan Med J 2012 2012/;59(6). 
 
 
(33) Oates DJ, Kornetsky D, Winter MR, Silliman RA, Caruso LB, Sharbaugh ME, et al. Minimizing Geriatric 
Rehospitalizations: A Successful Model. Am J Med Qual 2013 /;28(1):8-15. 
 
 
(34) Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, et al. Comprehensive discharge planning 
and home follow-up of hospitalized elders: A randomized clinical trial. J Am Med Assoc 1999 1999/02;281(7):613-620. 
 
 
 
Models of Care in the Transition from the Secondary to the Primary Sector among the Frailest Elderly +75; a Randomized Controlled Trial 
 
 
 
 

(35) Linertová R, García-Pérez L, Vázquez-Díaz JR, Lorenzo-Riera A, Sarría-Santamera A. Interventions to reduce 
hospital readmissions in the elderly. Value Health 2010 /;13(7):A406. 
 
 
(36) Shen E, Koyama SY, Huynh DN, Watson HL, Mittman B, Kanter MH, et al. Association of a dedicated post-
hospital discharge follow-up visit and 30-day readmission risk in a Medicare advantage population. JAMA Intern Med 
2017 2017/01;177(1):132-135. 
 
 
(37) Huntley AL, Chalder M, Shaw ARG, Hollingworth W, Metcalfe C, Benger JR, et al. A systematic review to identify 
and assess the effectiveness of alternatives for people over the age of 65 who are at risk of potentially avoidable hospital 
admission. BMJ Open 2017 2017/07;7(7). 
 
 
(38) Gonçalves-Bradley DC, Iliffe S, Doll HA, Broad J, Gladman J, Langhorne P, et al. Early discharge hospital at home. 
Cochrane Database Syst Rev 2017 2017/06;2017(6). 
 
 
(39) Altfeld SJ, Shier GE, Rooney M, Johnson TJ, Golden RL, Karavolos K, et al. Effects of an enhanced discharge 
planning intervention for hospitalized older adults: a randomized trial. Gerontologist 2013 /;53(3):430-440. 
 
 
(40) Nikolaus T, Specht-Leible N, Bach M, Oster P, Schlierf G. A randomized trial of comprehensive geriatric 
assessment and home intervention in the care of hospitalized patients. Age Ageing 1999 1999/;28(6):543-550. 
 
 
(41) Shepperd S, Iliffe S, Doll HA, Clarke MJ, Kalra L, Wilson AD, et al. Admission avoidance hospital at home. 
Cochrane Database Syst Rev 2016 2016/09;2016(9). 
 
 
(42) Coleman EA, Parry C, Chalmers S, Min S-. The care transitions intervention: Results of a randomized controlled 
trial. Arch Intern Med 2006 2006/09;166(17):1822-1828. 
 
 
(43) Harris R, Ashton T, Broad J, Connolly G, Richmond D. The effectiveness, acceptability and costs of a hospital-at-
home service compared with acute hospital care: A randomized controlled trial. J Health Serv Res Policy 2005 
/;10(3):158-166. 
 
 
(44) Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional Care of Older Adults 
Hospitalized with Heart Failure: A Randomized, Controlled Trial. J Am Geriatr Soc 2004 /;52(5):675-684. 
 
 
(45) Mas MA, Inzitari M, Sabate S, Santaeugenia SJ, Miralles R. Hospital-at-home Integrated Care Programme for the 
management of disabling health crises in older patients: comparison with bed-based Intermediate Care. Age Ageing 2017 
Nov 1;46(6):925-931. 
 
 
(46) Linertová R, García-Pérez L, Vázquez-Díaz JR, Lorenzo-Riera A, Sarría-Santamera A. Interventions to reduce 
hospital readmissions in the elderly: In-hospital or home care. A systematic review. J Eval Clin Pract 2011 /;17(6):1167-
1175. 
 
 
(47) Volpato S, Bazzano S, Fontana A, Ferrucci L, Pilotto A. Multidimensional Prognostic Index predicts mortality and 
length of stay during hospitalization in the older patients: a multicenter prospective study. J Gerontol A Biol Sci Med Sci 
2015 2015/03;70(3):325-331. 
 
 
(48) Daragjati J, Topinkova E, Puntoni M, Cruz-Jentoft A, Polidori MC, Paccalin M, et al. Multidimensional prognostic 
index (MPI) predicts re-hospitalization in frail older patients admitted to hospital: A multicentre, international, one-year 
follow-up study. the MPI-AGE European project. Eur Geriatr Med 2017 2017/09;8:S78-S79. 
 
 
(49) Vanderbilt University. REDCap. Available at: https://www.project-redcap.org/. Accessed November, 2017. 
 
 
 
 
 
 
 
 
 
 
Models of Care in the Transition from the Secondary to the Primary Sector among the Frailest Elderly +75; a Randomized Controlled Trial 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
Appendix 1A 
 
REGIONE DEL VENETO 
AZIENDA ULSS 16 PADOVA 
 
OSPEDALE S. ANTONIO 
 
Unità Operativa Complessa di GERIATRIA 
 
 
 
 
 
 
 
 
MULTIDIMENSIONAL PROGNOSTIC INDEX 
(MPI) * 
 
 
 
 
 
 
 
 
 
 
CO-HABITATION STATUS 
 
 
Does the patient live: 
Alone 
 
With relatives/nourse 
 
 
In institution 
 
 
 
 
 
 
 
 
 
MEDICATION USE 
 
 
Number of drugs used 
 
 
 
 
 
 
 
* Pilotto A, Ferrucci L, Franceschi M et al. Development and validation of a Multidimensional Prognostic Index for 1-Year 
Mortality from a Comprehensive Geriatric Assessment in Hospitalized Older Patients. Rejuvenation Res 2008;11:151-161. 
 
 
 
 

 
ACTIVITIES OF DAILY LIVING (ADL) * 
 
 
A) BATHING (either sponge bath, tub bath, or shower) 
 
- Receives no assistance (gets in and out of tub by self if tub is usual means of bathing) 
1 
- Receives assistance in bathing only one part of the body (such as back or a leg) 
1 
- Receives assistance in bathing more than one part of the body (or not bathed) 
0 
B) DRESSING (gets clothes from closets and drawers – including underclothes, outer garments, and using 
fasteners including braces, if worn) 
 
- Gets clothes and gets completely dressed without assistance 
1 
- Gets clothes and gets dressed without assistance except for assistance in tying shoes 
1 
- Receives assistance in getting clothes or in getting dressed, or stays partly or completely undressed 
0 
C) TOILETING (going to the "toilet room" for bowel and urine elimination, cleaning self after elimination, 
and arranging clothes) 
 
- Goes to "toilet room," cleans self, and arranges clothes without assistance (may use object for 
1 
support such as cane, walker, or wheelchair and may manage night bedpan or commode, 
emptying same in morning) 
- Receives assistance in going to "toilet room" or in cleaning self or in arranging clothes after 
0 
elimination or in use of night bedpan or commode 
- Doesn't go to room termed "toilet" for the elimination process 
0 
D) TRANSFER 
 
- Moves in and out of bed as well as in and out of chair without assistance (may be using object 
1 
for support such as cane or walker) 
- Moves in and out of bed or chair with assistance 
0 
 
- Doesn't get out of bed 
0 
E) CONTINENCE 
- Controls urination and bowel movement completely by self 
1 
- Has occasional "accidents" 
0 
- Supervision helps keep urine or bowel control, catheter is used, or is incontinent 
0 
F) FEEDING 
- Feeds self without assistance 
1 
- Feeds self except for getting assistance in cutting meat or buttering bread 
1 
- Receives assistance in feeding or is fed partly or completely by using tubes or intravenous fluids 
0 
 
 
 
TOTAL _________ 
 
 
 
* Katz S, Ford AB, Moskowitz RW et al. Studies of illness in the aged. The index of ADL: A standardized measure of biological and 
psychological function. JAMA 1963; 185: 914-19. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
INSTRUMENTAL ACTIVITIES OF DAILY LIVING SCALE (IADL)* 
 
 
A) ABILITY TO USE TELEPHONE 
 
- Operates telephone on own initiative: looks up and dials numbers, etc. 
1 
- Dials a few well-known numbers 
1 
- Answers telephone but does not dial 
1 
- Does not use telephone at all 
0 
B) SHOPPING 
- Takes care of all shopping needs independently 
1 
- Shops independently for small purchases 
0 
- Needs to be accompanied on any shopping trip 
0 
- Completely unable to shop 
0 
C) FOOD PREPARATION 
- Plans, prepares and serves adequate meals independently 
1 
- Prepares adequate meals if supplied with ingredients 
0 
- Heats, serves and prepares meals or prepares meals but does not maintain adequate diet 
0 
- Needs to have meals prepared and served 
0 
D) HOUSEKEEPING 
- Maintains house alone or with occasional assistance (e.g. “heavy work domestic help”) 
1 
- Performs light daily tasks such as dishwashing, bed making, etc. 
1 
- Performs light daily tasks but cannot maintain acceptable level of cleanliness 
1 
- Needs help with all home maintenance tasks 
0 
- Does not participate in any housekeeping tasks 
0 
E) LAUNDRY 
- Does personal laundry completely 
1 
- Launders small items; rinses stockings, etc. 
1 
- All laundry must be done by others 
0 
F) MODE OF TRANSPORTATION 
- Travels independently on public transportation or drives own car 
1 
- Arranges own travel via taxi, but does not otherwise use public transportation 
1 
- Travels on public transportation when accompanied by another 
1 
- Travel limited to taxi or automobile with assistance of another 
0 
- Does not travel at all 
0 
G) RESPOSIBILITY FOR OWN MEDICTIONS 
- Is responsible for taking medication in correct dosages at correct time 
1 
- Takes responsibility if medication is prepared in advance in separate dosage 
0 
- Is not capable of dispensing own medication 
0 
H) ABILITY TO HANDLE FINANCES 
- Manages financial matters independently (budgets, writes checks, pays rent, bills goes to bank), collects 
1 
and keeps track of income 
 
- Manages day-to-day purchases, but needs help with banking, major purchases, etc.                                        1 
- Incapable if handling money                                                                                                                              0 
 
TOTAL _________ 
 
 
 
* Lawton MP, Brody EM. Assessment of older people:self-maintaining and instrumental activities of daily living. Gerontologist 
1969;9:179-86. 
 
 
 
 
 

 
SHORT PORTABLE MENTAL STATUS 
QUESTIONNAIRE (SPMSQ) * 
(Record the errors) 
 
 
What is the date today? (Correct only when the month, date, and year are all correct) 
1 
What day of the week is it? 
1 
What is the name of this place? (Correct if any of the description of the location is given) 
1 
What is your street address? 
1 
How old are you? 
1 
When were you born? 
1 
Who is the president (or the Pope) now? (Requires only the correct last name) 
1 
Who was president (or the Pope) just before him? 
1 
What was your mother’s maiden name? 
1 
Subtract 3 from 20 and keep subtracting 3 from each new number at least for 3 times (The entire 
1 
series must be performed correctly to be scored as correct) 
 
 
TOTAL _________ 
 
 
 
* Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr 
Soc. 1975; 23:433-441. 
 
 
 
EXTON-SMITH SCALE (ESS) * 
(evaluation of pressure sores risk) 
 
 
General Condition 
 
Bad 
1 
Poor 
2 
Fair 
3 
Good 
4 
Mental State 
 
Stuporosous 
1 
Confused 
2 
Apathetic 
3 
Alert 
4 
Activity 
 
In bed all day 
1 
Chairfast 
2 
Walks with help 
3 
Ambulant 
4 
Incontinence 
 
Doubly incontinent 
1 
Usually of urine 
2 
Occasional 
3 
Not 
4 
Mobility in Bed 
 
Immobile 
1 
Very limited 
2 
Slightly limited 
3 
Full 
4 
 
 
TOTAL _________ 
 
Score 16-20: minimum risk 
Score 10-15: medium risk 
Score 5-9: high risk 
 
 
* Bliss MR., McLaren R., Exton-Smith AN. Mattresses for preventing pressure sores in geriatric patients. Mon Bull Minist Health 
Public Health Lab Serv 1966 
 
 
 
 
 
 
 
 

 
CUMULATIVE ILLNESS RATING SCALE (C.I.R.S.) * 
 
 
NONE 
MILD 
 
 
1. Cardiac (heart only) 
1 
2 
2. Hypertension (rating is based on severity) 
1 
2 
3. Vascular (arteries, veins, lymphatics) 
1 
2 
4. Respiratory (lungs, bronchi, trachea) 
1 
2 
5. EENT (eye, ear, nose, throat, larynx) 
1 
2 
6. Upper GI (esophagus, stomach, 
1 
2 
duodenum, biliary and pancreatic trees) 
7. Lower GI (intestines, hernias) 
1 
2 
 
8. Hepatic (liver only)                                              1             2 
9. Renal (kidneys only)                                            1             2 
10. Other GU (ureters, bladder, urethra, 
1 
2 
prostate, genitals) 
11. Musculo-skeletal-integumentary 
1 
2 
(muscles, bone, skin) 
12. Neurological (brain, spinal cord, nerves) 
1 
2 
 
13. Endocrine-metabolic (including diabetes, 
1 
2 
hyperlipidemia, infections, toxicity) 
14. Psychiatric (dementia, depression, 
1 
2 
anxiety, agitation, psychosis) 
MODERATE 
 
 
3 
3 
3 
3 
3 
3 
 
3 
3 
3 
3 
 
3 
 
 
3 
3 
 
3 
SEVERE 
EXTREMELY 
SEVERE 
4 
5 
 
4 
5 
4 
5 
4 
5 
4 
5 
4 
5 
 
4 
5 
4 
5 
4 
5 
4 
5 
 
4 
5 
 
 
4                       5 
4                       5 
 
4 
5 
 
 
ILLNESS SEVERITY SCORE (CIRS-IS) 
mean of all single item 
(excluded the psychiatric item) 
 
____________________________________________ 
COMORBIDITY INDEX (CIRS-CI) 
number of items with a score 
of 3 or greater (excluded the psychiatric item) 
 
_______________________________________ 
 
 
 
* Conwell Y, Forbes NT, Cox C, Caine ED. Validation of a measure of physical illness burden at autopsy: the Cumulative Illness 
Rating Scale. J Am Geriatr Soc 1993; 41: 38-41. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
MINI NUTRITIONAL ASSESSMENT (MNA) * 
 
A) Anthropometric Assessment 
1) Body Mass Index (BMI) 
Weight:________________kg 
Height:________________cm 
 
2) Mid-arm circumference 
(MAC) in cm___________ 
 
3) Calf circumference 
(CC) in cm_____________ 
 
4) Weight loss 
(last three months) 
 
B) General Assessment 
 
 
0 
BMI <19 
 
 
0 
MAC<21 
 
0 
CC < 31 
 
0 
loss > 3Kg 
 
 
1 
BMI = 19-20 
 
 
0.5 
MAC ≤ 22 
 
1 
CC ≥ 31 
 
1 
does not know 
 
 
2 
BMI = 21-22 
 
 
1 
MAC > 22 
 
 
 
2 
loss between 1-3Kg 
 
 
3 
BMI ≥ 23 
 
 
 
 
 
 
 
3 
no weight loss 
 
5) Lives independently (not in a nursing home or hospital) 
 0 
1 
no                    yes 
6) Takes more than 3 prescription drugs per day 
 0 
1 
yes                    no 
7) Has suffered psychological stress or acute disease in the past 3 months 
 0 
2 
yes                    no 
8) Mobility 
 
 
9) Neuropsychological problems 
0 
bed or chair bound 
 
0 
severe dementia or 
depression 
1 
able to get out of bed/chair but 
does not go out 
1 
mild dementia 
2 
goes out 
 
2 
no psychological problems 
 
10) Pressure sores or skin ulcers 
 
C) Dietary Assessment 
11) How many full meals does the 
0 
patient eat daily?                                                      1 meal 
0                       1 
yes                    no 
 
 
1 
2 
2 meals 
3 meals 
 
12) Consumes: 
Points if: 
1 yes 0 
2 yes 0.5 
3 yes 1 
at least 1 serving of dairy 
products (milk, cheese, 
yogurt) per day 
 
yes 
no 
2 or more servings of 
legumes or eggs per week 
 
 
yes 
no 
meat, fisk or poultry 
every day 
 
 
yes 
no 
 
13) Consumes 2 or more servings of fruits or 
0 
1 
vegetables per day?                                                                            no                                                         yes 
 
14) Has food intake declined over the 
past 3 months due to loss of appetite? 
 
15) How much fluidi s consumed per 
day? 
 
16) Mode of feeding 
 
 
D) Self Assessment 
17) Do they view themselves a s 
having nutritional problems? 
0 
severe loss of appetite 
 
0 
less than 5 glasses 
 
0 
with assistance 
 
 
 
0 
major malnutrition 
1 
moderate loss of appetite 
 
0.5 
5 to 9 glasses 
 
1 
self-feed with some 
difficulty 
 
 
1 
does not know 
2 
no loss of appetite 
 
1 
more than 9 glasses 
 
2 
self-feed without any 
problem 
 
 
2 
no nutritional problems 
 
18) In comparison with other 
people of same age, how they 
consider their health status? 
0 
not as good 
0.5 
1 
2 
does not know                    as good                           better 
 
TOTALE (max 30 punti)_____________ 
 
MALNUTRITION INDICATOR SCORE: ≥ 24 = well-nourished, 17-23.5 = at risk of malnutrition, < 17 = malnourished 
 
 
* Vellas B et al. The Mini Nutritional Assessment (MNA) and its use in grading the nutritional state of elderly patients. Nutrition 
1999; 15: 116-22. 
 
 
 
 

 
 
 
 
Normogram for 
the calculation 
of knee height 
 
 
 
 
 
 
 
 
MPI - Multidimensional Prognostic Index 
 
 
Score given to each domain 
 
 
 
 
SPMSQ a 
 
ESS b 
 
ADL c 
 
IADL c 
 
CIRS d 
 
MNA e 
 
Number of drugs 
 
Social status 
Low 
(Value = 0) 
 
0-3 
 
16-20 
 
6-5 
 
8-6 
 
0 
 
≥ 24 
 
0-3 
 
Lives with family 
Middle 
(Value = 0.5) 
 
4-7 
 
10-15 
 
4-3 
 
5-4 
 
1-2 
 
17 to 23.5 
 
4-6 
 
Institutionalized 
High 
(Value = 1) 
 
8-10 
 
5-9 
 
2-0 
 
3-0 
 
≥ 3 
 
<17 
 
≥ 7 
 
Living alone 
 
Add up the scores assigned to each domain, and then 
divide the sum by 8 
 
TOTAL SCORE 
 
 
Legend: 
RISK 
 
RANGE 
 
 
Mild (MPI 1) 
 
 
0.00 - 0.33 
 
 
Moderate (MPI 2) 
 
 
0.34-0.66 
 
 
Severe (MPI 3) 
 
 
0.67-1.0 
 
to Number of errors 
b Exton Smith Scale Score: 16-20, minimum risk, 10-15, moderate risk; 5-9, high risk of developing 
c Number of active functional activities 
d Number of pathological (score> 3) 
e ≥ 24: satisfactory; 17-23.5: at risk of malnutrition; <17: Malnutrition 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
Appendix 1B 
 
  
(Slightly adjusted and translated (to Danish) version of Appendix 1A had to be removed since uploaded 
documents must be in English. If requested, Appendix 1B can be provided by the Record Owner Troels K. 
Hansen.) 
 
 
 
 
 
 

  
 
 
 
 
 
 
 
 
 
 
 
Appendix 2 
 
 
Usual post-discharge follow-up care 
Usual care during transition comprises individualized discharge planning. In all cases, GPs receive an electronically 
transmitted discharge summary and an updated prescription list at discharge. Municipality services receive rehabilitation-
and personal care plans and discharge reports made by hospital nurse. Post-discharge follow-up follows no fixed 
schedule or programme, thereby leaving assessment of care- and follow-up services to the municipality services, based 
on recommendations from hospital nurses and physicians. A variety of temporary and permanent nursing home facilities, 
rehabilitation units and other institutional living facilities exists. 
Follow-up at home may include a visit by a community nurse and establishing or continuation of home care. Depending 
on screening during hospitalization, hospital nurses can by referral recommend a GP conducted home visit to patients 
aged 65 years or older. The actual execution of this home visit depends on the GPs judgment of its necessity. 
The screening process, leading to the proposal of a GP-conducted home visit, is based on data related to LOS, former 
admissions within the past year, functional status, state of nutrition, morbidity, medication, cognitive status, substance 
abuse, psychiatric diseases and coping ability. If the score is ≥23, and the patient consents, the information is reported to 
the municipal health service and the GP. GPs may also on their own initiate a follow-up visit. The Danish College of 
General Practitioners recommends that the GP assesses the need for visit according to the following criteria: 

Health related issues: patients suffering from reduced functional or health related status prior to admission, need 
for assessment of medication, chronically and severely ill, impairment due to dementia, terminal illness. 
Organizational issues: patients readmitted, extended length of stay, need for assessment of coordinated efforts 
Social issues: frail and uneasy patients, weak social network, patients living alone, patients recently widowed 
If conducted, the home visit is performed within 8 days after discharge by the GP and/or community nurse. The contents 
of this intervention may be: 

Evaluation of the discharge summary including changes of medication and specific follow-up needs specified. 

Overall health assessment including functional status, for instance by means of chair stand test 

Assessment of need for care and facilities 

Medication review 

Joint decision and plan 
 
According to head nurses in the medical wards at Randers Regional Hospital, the screening and assessment of GP 
conducted follow-up visits is performed as a standard to all patients aged 65 years or older. Due to busyness, screening 
may sometimes be given low priority, particularly when knowing that many patients do not receive a visit despite 
referral. This is reflected in the recent data showing the numbers of screenings, number of referrals to and completion of 
visits (1). 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1: http://www.sundhedsaftalen.rm.dk/projekter/opfolgende-hjemmebesog/ 
 
 
 

  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Appendix 3 
 
Year 
Jan Feb Mar Apr May 
Jun Jul Aug Sep Oct Nov Dec 
 
 
2017 Pilot study MPI 
X 
X 
X 
X 
X 
X 
 
 
Writing protocol 
 
 
Randomization pilot 
MPI at discharge pilot 
Inclusion (Intervention) 
2018 Inclusion (Intervention) 
X 
X 
X 
X 
X 
Writing article (method) 
2019 Validation study 
X 
X 
X 
 
Inclusion (Intervention) 
X 
X 
X 
X 
X 
Inclusion (Control) 
X 
X 
X 
X 
X 
PhD (until December 2021) 
X 
X 
X 
X 
X 
Follow-up ends (Intervention) 
Analyzing data (Intervention) 
Writing articles 
2020 Writing articles 
X 
X 
X 
X 
X 
Follow-up ends (Control) 
X 
Analyzing data (Control) 
X 
X 
X 
X 
Writing PhD thesis                                    X 
X 
X 
1 month abroad 
2021 Writing PhD thesis 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
X       X      X 
X       X      X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
X 
X 
 
X       X      X       X       X      X       X 
X       X      X       X       X      X       X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
X       X      X       X       X      X       X 
X       X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Intervention cohort: inclusion and exclusion 
 
 
 
Fig. 1 
Eligible patients: All admitted 
geriatric patients aged 75 years 
or older 
 
 
 
 
 
 
Living in 
Aarhus 
Municipality 
 
 
 
 
 
 
 
 
 
 
Included in other follow-up schemes 
 
 
 
 
Terminally ill at admission 
 
 
 
 
 
Living at Vikærgården 
 
 
Study population 
 
 
 
Allready included 
 
 
Randomization 
 
 
Transferred to other department 
Drop-out during admission 
 
 
Discharged to Vikærgården 
 
 
Frailty screening (MPI) 
 
Baseline 
 
MPI=1 
 
 
 
Discharge to follow-up according to 
randomization 
 
 
 

Randomization, discharge and follow-up 
 
 
 
Fig. 2 
Randomized at 
admission 
 
 
 
 
 
I 
 
Community 
nurse follow-up 
II 
 
Geriatric team 
follow-up 
 
 
 
 
 
MPI screening at 
discharge 
 
 
 
 
 
 
 
 
 
MPI = 1 
 
MPI = 2 
MPI = 3 
Baseline data 
 
MPI = 1 
MPI = 2 
MPI = 3 
 
 
 
 
 
 
 
 
 
 
Follow-up referring to 
individualized planning 
 
(Excluded) 
 
Follow-up in 
accordance with 
randomization 
 
 
 
 
 
 
 
 
Outcome measures: 
 
- Readmission, Time at home, Duration of readmission 
 
- Mortality 
 
- Length of stay 
 
- Direct discharge from the ED 
 
- Functional status 
 
 
- PROMs 
 
 
 

 
 
Fig. 3 
 
 
 
 
Geriatric 
wards 1 and 
2, AUH 
 
 
 
 
Emergency 
department, 
AUH 
 
 
 
 
 
PhD student 
Troels 
Kjærskov 
Hansen 
 
Emergency 
Department, RRA 
 
Control group 
 
Medical wards 1, 
2, 3 and 4 RRA 
 
Control group 
 
 
 
 
 
Main 
supervisor 
 
Else Marie 
Damsgaar 
d 
 
 
Geriatric 
department, 
AUH 
 
 
 
Research 
unit 
Research 
assistant 
 
 
Medical 
department, RRA 
 
 
 
 
Co-
supervisor 
Merete 
Gregersen 
 
 
 
 
Geriatric team 
 
Intervention II 
 
 
 
 
 
Aarhus 
Municipality 
Research 
Assistant 
Sofie 
Bossen  
 
Co-
supervisors 
Seham 
Shahla & Jens 
Meldgaard 
Bruun 
 
 
 
 
Home 
GP 
care 
 
 
Community 
nurses 
 
Intervention 
I 
Usual care follow-
up: 
 
Other 
municipalities 
 
GP