Integrated Care Pathways in a Community Setting

Study Results

Results pending

The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.

Basic Information

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Recruitment Status

COMPLETED

Clinical Phase

NA

Total Enrollment

304 participants

Study Classification

INTERVENTIONAL

Study Start Date

2009-10-31

Study Completion Date

2012-10-31

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.

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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.

Conditions

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Chronic Illness

Study Design

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Allocation Method

RANDOMIZED

Intervention Model

PARALLEL

Primary Study Purpose

HEALTH_SERVICES_RESEARCH

Blinding Strategy

NONE

Study Groups

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Integrated care pathway

program for

1. communication and information flow aimed at collaboration between hospitals, general practitioners and home care services
2. systematic patient follow-up in home care services by using checklists

Group Type EXPERIMENTAL

integrated care pathway

Intervention Type OTHER

communication and follow-up program for integrated care

usual care

Group Type ACTIVE_COMPARATOR

usual care

Intervention Type OTHER

Interventions

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integrated care pathway

communication and follow-up program for integrated care

Intervention Type OTHER

usual care

Intervention Type OTHER

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.