Bridging the Gap: Creating a Continuum of Care

NCT ID: NCT06368674

Last Updated: 2025-04-11

Basic Information

• Recruitment Status: RECRUITING
• Clinical Phase: NA
• Total Enrollment: 150 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2024-06-06
• Study Completion Date: 2027-02-01

Brief Summary

Coordination and integration between care settings is essential for the quality of care of frail older patients. An active follow-up by a case manager (CM) after discharge form an acute geriatric hospital ward has the potential to bridge the gap between hospital, primary and municipality care for frail older people. This study evaluates the effects of an active follow-up by a CM in primary care after discharge from a geriatric ward, with the following research questions: Can an active follow-up by CM for frail older people discharged from an acute geriatric ward, compared to those not receiving active follow up, Maintain/increase independence in activities of daily living, self-rated health and life satisfaction? Increase satisfaction with health care? Reduce health care consumption/be cost-effective? How feasible is the intervention and the study design from the perspective of the caregivers and the older person? This is a clinical controlled study with a process evaluation. Inclusion criteria are 75 years or older, frail and admitted to a geriatric ward.

This study is relevant since today's highly specialized acute care is poorly adapted to the comprehensive needs of frail older people, and exposes them to avoidable risks such as loss of functional capacities causing unnecessary care needs and decreased wellbeing. Active follow-up by a CM after discharge may be an important way to integrate the care for frail older people, after receiving in-hospital geriatric care. This can improve the quality of care for this vulnerable group, and direct the right health care actions towards those in most need.

The intervention is a active follow-up after discharge by a CM (nurse) in primary care. CM will secure that discharge and care plans are executed and to address new needs. If there are unmet needs, the CM will ensure that adequate actions are performed to meet the needs. The intervention group consists of participants discharged to a primary health care centre with a CM, who actively follows-up after discharge. The control group consists of participants discharged to a primary health care centre without CM, and thereby no active follow-up after discharge. All participants will be followed-up by the research team during one year, concerning dependence in activities of daily living, self-rated health, health care consumption and satisfaction with care.

Conditions

Frailty; Dependence; Integrated Care

Study Design

• Allocation Method: NON_RANDOMIZED
• Intervention Model: PARALLEL
• Primary Study Purpose: SUPPORTIVE_CARE
• Blinding Strategy: SINGLE

Study Groups

Intervention group Case Manager (CM)

The intervention group will receive extra follow-up by a CM after discharge.

Group Type: EXPERIMENTAL

Intervention group Case Manager (CM)

Intervention Type: OTHER

The CM will be informed about the discharge plan from the nurse at the geriatric ward, as will the municipality for those with need of home help care. An outline of the intervention has been created with managers from primary care and rehabilitation within primary care and municipality care. Core components in the intervention will be active follow-up of the discharge, rehabilitation and care plans. If there are plans that have not been executed or unmet needs, the CM will take adequate contacts to ensure that actions are made to meet the needs. These contacts can be, e.g. the GP for medical needs, the rehabilitation unit in primary or municipality care for unmet rehabilitation needs, and the home help service for unmet care needs. The CM will have a network of contact persons in hospital, primary and community care, as well as in rehabilitation in primary and community care, in order to facilitate for prompt actions to meet the needs.

Control group

The control group will receive usual follow-up after discharge, i.e. no active follow-up

Group Type: OTHER

Control Group

Intervention Type: OTHER

The participants in the control group with a planned follow-up by a primary health care centre within the catchment area of the Sahlgrenska University Hospital that does not have CMs designated for active follow up of discharged frail older people. Thus, the participants in the control group will not actively be followed-up after discharge.

Interventions

Intervention group Case Manager (CM)

The CM will be informed about the discharge plan from the nurse at the geriatric ward, as will the municipality for those with need of home help care. An outline of the intervention has been created with managers from primary care and rehabilitation within primary care and municipality care. Core components in the intervention will be active follow-up of the discharge, rehabilitation and care plans. If there are plans that have not been executed or unmet needs, the CM will take adequate contacts to ensure that actions are made to meet the needs. These contacts can be, e.g. the GP for medical needs, the rehabilitation unit in primary or municipality care for unmet rehabilitation needs, and the home help service for unmet care needs. The CM will have a network of contact persons in hospital, primary and community care, as well as in rehabilitation in primary and community care, in order to facilitate for prompt actions to meet the needs.

Intervention Type: OTHER

Control Group

The participants in the control group with a planned follow-up by a primary health care centre within the catchment area of the Sahlgrenska University Hospital that does not have CMs designated for active follow up of discharged frail older people. Thus, the participants in the control group will not actively be followed-up after discharge.

Intervention Type: OTHER

Eligibility Criteria

Inclusion Criteria

75 years or older, screened as frail, admitted to an acute geriatric ward working according to CGA at the Sahlgrenska or Mölndal hospital. Both hospitals are part of Sahlgrenska University hospital, with the same catchment area, including Gothenburg with surrounding municipalities. People in the region can seek care at both hospitals. The orthopaedic clinic is situated at Mölndal hospital, resulting in most patients with fractures being admitted to this hospital, irrespective of in which municipality they are living. Cognitive impairment is not an exclusion criterion. For people who cannot give informed consent due to cognitive impairment, next of kin will be asked to assist with the consent.

Exclusion Criteria

Less that 75 years old, Not residing in a permanent residence.

• Minimum Eligible Age: 75 Years
• Eligible Sex: ALL
• Accepts Healthy Volunteers: No

Sponsors

Vastra Gotaland Region

OTHER_GOV

Sponsor Role: collaborator

Sahlgrenska University Hospital

OTHER

Sponsor Role: collaborator

Forte

INDUSTRY

Sponsor Role: collaborator

Göteborg University

OTHER

Sponsor Role: lead

Responsible Party

Responsibility Role: SPONSOR

Locations

University of Gothenburg

Gothenburg, , Sweden

Site Status: RECRUITING

Countries

Sweden

Central Contacts

Theresa Westgård, PhD, Associate Professor

Role: CONTACT

Theresa.westgard@neuro.gu.se

18628820334

Isabelle Andersson Hammar, PhD, Associate Professor

Role: CONTACT

Isabelle.a-h@neuro.gu.se

+46766185719

Facility Contacts

Isabelle Andersson Hammar, PhD, Associate Professor

Role: primary

Isabelle.a-h@neuro.gu.se

+46766185719

Other Identifiers

2023-00363

Identifier Type: -

Identifier Source: org_study_id