Clinical trial NCT06190288: AdvantAGE: Implementation and Evaluation of an Interprofessional Tranistional Care Model for Frail Older Adults
Official title: AdvantAGE: Implementation and Evaluation of an Interprofessional Transitional Care Model for Frail Older Adults at the University Department of Geriatric Medicine FELIX PLATTER
Study type: INTERVENTIONAL
Overall status: RECRUITING
Phase: NA
Conditions: Transitional Care
Multimorbidity
Geriatric Care
Keywords: Transitional Care, Frailty, Rehospitalisation, Geratric Care
Lead sponsor: University Department of Geriatric Medicine FELIX PLATTER
Sponsor class: OTHER
Collaborators: name: Health Department of the Canton of Basel-Stadt
First posted: 2024-01-05
Enrollment: 250
Sex: ALL
Minimum age (years): 65
Standard ages: OLDER_ADULT
Accepts healthy volunteers: no
Allocation: NA
Intervention model: SINGLE_GROUP
Intervention model description: Hybrid effectiveness-implementation study (type 1)
Primary purpose: HEALTH_SERVICES_RESEARCH

Brief summary: This clinical trial at the University Department of Geriatric Medicine FELIX Platter in Basel, Switzerland, is designed to evaluate a new transitional care model aimed at helping frail older adults after they get discharged from the hospital. The AdvantAGE study aims to explore the following questions:

* Does the new care model help reduce the number of patients who need to return to the hospital within 90 days?
* How effective is the implementation of this care model?

Participants in the trial will be followed by advanced practice nurses for up to 90 days after hospital discharge. The patients and their caregivers will receive support in coordinating care, managing medications, and learning to manage the patient's health conditions on their own. Additionally, they will have the opportunity to engage in discussions about advanced care planning.


Eligibility criteria: Inclusion Criteria:

* Currently admitted to the acute or rehabilitation ward of University Department of Geriatric Medicine
* Reside in Basel-Stadt
* Possess the ability to speak and comprehend the German language
* Scheduled to be discharged to their home
* 65 years or older
* Identified by a clinician as having a high risk of deterioration due to frailty

Additionally, participants must meet at least one of the following criteria:

* diagnosed with a complex chronic disease requiring support in self-management and disease management, or
* facing socially challenging situations such as living alone without a supportive network or lacking a GP, or
* admitted for an acute illness with a brief hospital stay (e.g., infection, cardiac decompensation) and need support in self- and disease management, and continuity of the therapy plan, including close monitoring.

Exclusion Criteria:

* residing in a nursing home or being newly admitted to one
* lacking informal caregivers and exhibiting severe cognitive impairment (MMS ≤23)
* scoring \<50 on the motoric domain of the Functional Independence Measure (FIM)
* having a psychiatric disorder that significantly impacts their ability to manage daily life at time of the discharge

Primary outcomes:
measure: 90-days rehospitalization rate
timeFrame: 90 days post-discharge
Secondary outcomes:
measure: 30-days rehospitalization rate
timeFrame: 30 days post-discharge
measure: Time to readmission
timeFrame: Up to 90 days post-discharge
measure: Number of emergency room visits
timeFrame: 90 days post-discharge
measure: Time to emergency room visit
timeFrame: Up to 90 days post-discharge
measure: Patient's health-related quality of life
timeFrame: Up to 90 days post-discharge
measure: Patient satisfaction questionnaire
timeFrame: up to 90 days post-discharge
Other outcomes:
Locations:
city: Basel
country: Switzerland
facility: Universitäre Altersmedizin FELIX PLATTER
Study officials:
affiliation: Universitäre Altersmedizin FELIX PLATTER
name: Thekla Brunkert, PhD
role: PRINCIPAL_INVESTIGATOR
References: