Development and Testing of an Interprofessional, Person-centered Care Concept for People Living at Home With Care Needs.

Study Overview
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Brief Summary
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The aim of the project is to develop and pilot measures to optimize the person-centered cooperation between nursing services, general practitioners and members of the therapeutic professions in the care of people living at home with care needs, so that hospital admissions and the use of unplanned medical and rescue services are avoided, the quality of life is improved and a deterioration in the need for long-term care can be stopped. This is done by developing an interprofessional person-centered collaboration-concept, perform an explorative mixed-methods-study: interviews, focus groups, expert workshops, survey of best practices, shadowing, questionnaires.

Detailed Description
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Description of mixed-methods-study: Interviews with 20 patients, 20 relatives, 5 experts of health insurance professionals, and 3 focus groups à 8 persons with general practioniers, nurses, therapists. investigation of best practice cases explorative survey of 100 cases in each group: general practitioner nursing services therapists persons in need of care family members of persons in need of care The mixed-methods-study is analysed in different ways: structured content analysis case-based qualitative analysis of interviews descriptive analysis The mixed-methods-study has been approved by the ethics committee and is recruiting.

Official Title
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Development and Testing of an Interprofessional, Person-centered Care Concept for People Living at Home With Care Needs.

Conditions
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Utilization of Nursing, Medical and Therapeutical Care of People Living at Home With Care Needs

Intervention / Treatment
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* Other: interprofessional, person-centered care concept


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: years of age >18 receipt of benefits in the form of outpatient care according to SGB XI, preliminary / final classification of care ≥level 2 expected life expectancy >6 months informed consent sufficient opportunity to answer answering questions about patient-reported outcomes Exclusion Criteria: Living in nursing home / planned move-in within the following 6 months claim acceptance of SAPV participation in scientific study

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Supportive Care
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Interventional group<br>Implementation of interprof Home measures to improve cooperation between nursing services, general practitioners and members of the therapeutic professions in the care of people living at home with care needs. | Other: interprofessional, person-centered care concept<br>* interprofessional, person-centered care concept<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| cumulative number of hospitalisation | Cumulative incidence of hospitalisations within 12 months | 40 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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interprofessional collaboration, reduction of hospitalisation, people living at home with care needs