Models of Care in the Transition From the Secondary to the Primary Sector Among the Frailest Elderly

Study Overview
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Brief Summary
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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). A large part of the elderly population is at high risk of hospitalization including more admissions and increased morbidity and mortality. The number of hospital beds is declining persistently, calling for shorter lengths of stay (LOS). 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.

Detailed Description
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Design Population: The frailest acutely admitted geriatric patients aged +75. Intervention: Early follow-up visits after discharge. Comparison: Usual care follow-up. 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 (LOS), direct discharge from the Emergency Department, time at home before readmission, duration of readmission and physical functional status 30 days after discharge. Methods The first study is conducted as a randomized controlled trial (RCT) using two different degrees of intervention. The second study is a cohort study of an unexposed control group. The third study is sub-group analyses of the RCT data according to frailty status and type of dwelling. A focus group comprised of included patients and relatives will be set to identify additional patient related outcome measures (PROMs) and to participate in an advisory group throughout the remaining project.

Official Title
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Models of Care in the Transition From the Secondary to the Primary Sector Among the Frailest Elderly +75; a Randomized Controlled Trial

Conditions
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Frail Elderly Syndrome, Transitional Care, Frailty, Readmission, Aging, Elderly

Intervention / Treatment
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* Other: Early follow-up visit after discharge
* Other: Comprehensive geriatric assessment (CGA)
* Other: Continued geriatric care
* Other: Possible follow-up visit from GP


Participation Criteria
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Eligibility Criteria
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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 Discharge or transfer to another department, including hospice MPI-score = 1 (low frailty) Discharged to one specific temporary nursing home with geriatric medical assistance The patient does not want a visit after discharge

Ages Eligible for Study
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Minimum Age: 75 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
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Intervention I<br>Intervention (I): early follow-up visit from the community nurse within 24 hours after discharge | Other: Early follow-up visit after discharge<br>* Early follow-up visit and different degrees of specialized care after discharge<br>Other: Comprehensive geriatric assessment (CGA)<br>* Comprehensive geriatric assessment (CGA) during admission<br>|
| Experimental: Intervention II<br>Intervention (II): early follow-up by the geriatric team within 24 hours after discharge | Other: Early follow-up visit after discharge<br>* Early follow-up visit and different degrees of specialized care after discharge<br>Other: Comprehensive geriatric assessment (CGA)<br>* Comprehensive geriatric assessment (CGA) during admission<br>Other: Continued geriatric care<br>* Continued specialized geriatric care after discharge<br>|
| Other: Control<br>Usual care: individualized follow-up performed by the GP and municipality services | Other: Possible follow-up visit from GP<br>* Usual care: follow up visit from GP within one week after discharge<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Readmission | Readmission within 30 days after discharge | 30 days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Mortality | Mortality within 90 days after admission and 30 days after discharge | 90 days after admission and 30 days after primary discharge | 
| Length of stay (LOS) | Length of stay during primary admission and total length of stay including following readmissions | 30 days after primary discharge | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Elderly, Hospital at home, Readmission, Transitional care, Frailty, Patient Related Outcome Measures