Municipality-based Post-discharge Follow-up Visits

Study Overview
=================
Brief Summary
-----------------
The purpose of this study is to determine whether discharge follow-up visit by primary physician and community-based nurse affects the risk of early re-hospitalisation among high risk older people discharged from a medical ward.

Official Title
-----------------
Effect of Municipality-based Post-discharge Follow-up Visit Including the Primary Physician on Early Re-hospitalization in High Risk People of 65+ Years. A Randomised Controlled Trial.

Conditions
-----------------
Frailty, Readmission, Transition, Primary Care

Intervention / Treatment
-----------------
* Behavioral: Receive municipality-based follow-up visit


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Patient geography (The participant live in; Holbæk Kommune, Odsherred Kommune or Kalundborg Kommune.) Discharged from medical ward Holbæk Sygehus. Frailty (Rated by following criterion: dementia or a minimum of two of the following conditions; two or more hospitalisations within 12 month prior to follow up, los of physical function, treatment of two or more concurrent medical and/or surgical conditions, psychiatric disease, multi-pharmacy of more than 6 prescription medication, suspicious of congenital disturbances, substance abuse problem, disadvantaged social network, need for increasing home care following index hospitalization.) Exclusion Criteria: Not discharged to home (If the patient are not discharged to home.) No written consent (If the patient does not wish to participate / written consent are not signed.)

Ages Eligible for Study
-----------------
Minimum Age: 65 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Follow-up visit<br>Receive municipality-based follow-up visit including primary physician. | Behavioral: Receive municipality-based follow-up visit<br>* Systematic electronic referral from hospital to municipality of high risk people at discharge from a medical ward. Contact from municipality service to primary physician and citizen, to arrange first home visit within 7 days with focus on: medication, rehabilitation plan and health care appointments, functional level and need for further health care initiatives. The visit is concluded by planning of further visits (up till tree) and division of responsibilities between primary physician and the municipality service.<br>* Other names: Intervention group;|
| No Intervention: Usual care<br>Does not receive follow-up visit | |

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Re-admission | The primary outcome is re-hospitalisation rate within 30 days from discharge. Data is obtained from the official register of danish patients (Landspatientregistret). | Within 30 days from discharge | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Long-term hospitalization rate | Secondary outcome concerns hospitalization rate measured at 30 and 180 days post discharge. Data is obtained from the official register of Danish patients (Landspatientregistret). | Within 180 days from discharge | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
frailty, readmission, transition, discharge, primary care