Continuum of Care for Frail Elderly People

Study Overview
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Brief Summary
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The present study Continuum of care for frail elderly people form part of the research programme Support for frail elderly persons - from prevention to palliation (www.vardalinstitutet.net) which comprises research into three interventions. The program comprises interventions addressing frail elderly people in different phases of the disablement process, from elderly people who are beginning to develop frailty to very frail elderly people receiving palliative care. The intervention Continuum of care for frail elderly people addresses elderly people who are frail and that have a great risk of high health care consumption. The hypothesis is that an intervention program for frail elderly people can reduce the number of visits to the emergency department, increase the life satisfaction and maintain the functional ability. The intervention, including an early geriatric assessment at the emergency department, early family support, a case manager in the community with a multi-professional team and active follow-up by the case manager, contributes to early recognition of the elderly people's need of information, care and rehabilitation and of informal caregivers' need of information. It enhances the transfer of information and integrates the care between different caregivers and different care levels, thereby better recognize frail elderly people's needs. Specifically, this study is expected to show that the intervention has a positive effect on the frail elderly person's functional ability, life satisfaction, satisfaction with health and social care, and health care consumption.

Official Title
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Continuum of Care, From the Emergency Ward to Living at Home - Implementation and Evaluation of an Intervention for Frail Elderly People

Conditions
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Frail Elderly People

Intervention / Treatment
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* Other: integrated health care chain


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: 80 years and older or 65 to 79 years and having at least one chronic disease and being dependent in at least one activity of daily living Exclusion Criteria: acute severely sick who immediately needs the assessment of a physician (within ten minutes) those with diagnosis of dementia (or severe cognitive impairment) patients in palliative care

Ages Eligible for Study
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Minimum Age: 65 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 |
| --- | --- |
| No Intervention: Conventional care, controlgroup<br>conventional care, control group | |
| Experimental: integrated health care chain<br>integrated health care chain. Geriatric assessment at emergency department (ED), case manager with multiprofessional team in the community, support for informal caregivers | Other: integrated health care chain<br>* Geriatric assessment at ED, case manager with multiprofessional team in the community, support for informal caregivers<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Health Care Consumption | Number of hospital days and admission will be analysed | 1 year | 
| Dependence in Activities of Daily Living | Changes in number of person dependent in one or more daily activity from baseline to follow-up. | 1 year | 
| Satisfaction With Health and Social Care |  | 1 year | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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very frail, case manager, integrated care, multiprofessional, intervention