Clinical trial NCT01107119: Integrated Care Pathways in a Community Setting
Official title: Enabling Elderly Patients to Manage Their Own Lives - A Systematic Management Program for Home Care Services.
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Chronic Illness
Keywords: Frail elderly
Chronic illness
Integrated care model
Clinical pathways
Home care services
Lead sponsor: Norwegian University of Science and Technology
Sponsor class: OTHER
Collaborators: name: The Research Council of Norway
name: St. Olavs Hospital
name: Nordmøre and Romsdal Hospital Trust
name: City of Trondheim
name: Local authorities of Orkdal
name: Local authorities of Surnadal
name: Local authorities of Sunndal
name: Local authorities of Fræna
First posted: 2010-04-20
Enrollment: 304
Sex: ALL
Minimum age (years): 70
Standard ages: OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: HEALTH_SERVICES_RESEARCH

Brief summary: 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: 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.

Eligibility criteria: 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.

Primary outcomes:
measure: activities of daily living (ADL)
timeFrame: 6 and 12 months
measure: Institutional health care at primary and secondary level
timeFrame: 1 year
Secondary outcomes:
measure: Achieve better collaboration within primary care and between primary- and secondary health care providers
timeFrame: 1 year
Other outcomes:
Locations:
city: Fræna
country: Norway
facility: Fræna Municpality
city: Molde
country: Norway
facility: Molde hospital
city: Orkdal
country: Norway
facility: Orkdal Municipality
city: Sunndal
country: Norway
facility: Sunndal Municiplaity
city: Surnadal
country: Norway
facility: Surnadal Municipality
city: Trondheim
country: Norway
facility: St Olav's University hospital
city: Trondheim
country: Norway
facility: Trondheim municiplaity
Study officials:
affiliation: Norwegian University of Science and Technology
name: Anders Grimsmo, md phd
role: PRINCIPAL_INVESTIGATOR
References:
citation: Rosstad T, Garasen H, Steinsbekk A, Sletvold O, Grimsmo A. Development of a patient-centred care pathway across healthcare providers: a qualitative study. BMC Health Serv Res. 2013 Apr 1;13:121. doi: 10.1186/1472-6963-13-121.
citation: Rosstad T, Garasen H, Steinsbekk A, Haland E, Kristoffersen L, Grimsmo A. Implementing a care pathway for elderly patients, a comparative qualitative process evaluation in primary care. BMC Health Serv Res. 2015 Mar 4;15:86. doi: 10.1186/s12913-015-0751-1.
citation: Rosstad T, Salvesen O, Steinsbekk A, Grimsmo A, Sletvold O, Garasen H. Generic care pathway for elderly patients in need of home care services after discharge from hospital: a cluster randomised controlled trial. BMC Health Serv Res. 2017 Apr 17;17(1):275. doi: 10.1186/s12913-017-2206-3.