Integrated Care Pathways in a Community Setting

Study Overview
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Brief Summary
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The ambition of this study is to raise the quality of care for old and chronically ill patients by establishing a sustainable, systematic prevention and integrated care model for users of home care services. In this cluster randomized study the intervention will be carried through in five municipalities and three general hospitals. The home care units in every municipality will be randomized to either intervention og control units.

Detailed Description
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The primary objective of this study is to develop a functional and integrated care model between primary and secondary health care that will meet the needs both in the city and in smaller rural areas. The secondary objective of this study is to reduce the need of care at primary and secondary level through a a systematic and integrated follow-up by home care nurses and general practitioners to: Enable these patients to manage their health needs more efficiently and independently Achieve better collaboration within primary care Achieve better collaboration between primary- and secondary health care professionals Achieve increased satisfaction and confidence with the health care services by the users and their relatives both for included patients and other patients receiving home care services. Promote health and prevent unnecessary decline in health Strengthen the patients' ability to manage their daily activities.

Official Title
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Enabling Elderly Patients to Manage Their Own Lives - A Systematic Management Program for Home Care Services.

Conditions
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Chronic Illness

Intervention / Treatment
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* Other: integrated care pathway
* Other: usual care


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Person 70 years or above being discharged from the general hospital Will receive home care services within four weeks after being discharges from the hospital. Exclusion Criteria: Do not agree or are not able to agree to participate Is already involved in other research studies affecting the home care services.

Ages Eligible for Study
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Minimum Age: 70 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: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Integrated care pathway<br>program for communication and information flow aimed at collaboration between hospitals, general practitioners and home care services systematic patient follow-up in home care services by using checklists | Other: integrated care pathway<br>* communication and follow-up program for integrated care<br>|
| Active Comparator: usual care<br>usual care | Other: usual care<br> <br> |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| activities of daily living (ADL) | Individbasert pleie- og omsorgsstatistikk (IPLOS) scale, and Nottingham Extended ADL Scale | 6 and 12 months | 
| Institutional health care at primary and secondary level | Readmission (30 days)and inpatient hospital stays, number and length of stay (EPJ hospitals) Number and length of stay in municipal nursing homes (EPJ municipals) Days before permanent stay in municipal nursing homes | 1 year | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Achieve better collaboration within primary care and between primary- and secondary health care providers | Extract information on communication from EPJ municipal care and EPJ General practitioners | 1 year | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Frail elderly, Chronic illness, Integrated care model, Clinical pathways, Home care services