Improving care for frail older patients after hospital discharge
Bridging the Gap: Creating a Continuum of Care Through Active Follow-up by a Case Manager After Discharge - a Controlled Study
NA · Göteborg University · NCT06368674
This study tests if having a case manager follow up with frail older patients after they leave the hospital can help them stay independent, feel better about their health, and be more satisfied with their care.
Quick facts
| Phase | NA |
|---|---|
| Study type | Interventional |
| Enrollment | 150 (estimated) |
| Ages | 75 Years and up |
| Sex | All |
| Sponsor | Göteborg University (other) |
| Locations | 1 site (Gothenburg) |
| Trial ID | NCT06368674 on ClinicalTrials.gov |
What this trial studies
This study evaluates the impact of active follow-up by a case manager on frail older patients discharged from an acute geriatric hospital ward. It aims to assess whether this follow-up can help maintain or increase independence in daily activities, improve self-rated health and life satisfaction, enhance satisfaction with healthcare, and reduce healthcare consumption. The study will compare outcomes between patients receiving active follow-up and those who do not, while also considering the feasibility of the intervention from the perspectives of both caregivers and patients.
Who should consider this trial
Good fit: Ideal candidates are individuals aged 75 and older who are screened as frail and have been admitted to an acute geriatric ward.
Not a fit: Patients younger than 75 years or those not residing in a permanent residence may not benefit from this study.
Why it matters
Potential benefit: If successful, this approach could significantly enhance the quality of care and independence for frail older adults post-discharge.
How similar studies have performed: Other studies have shown positive outcomes with similar integrated care approaches for frail older adults, indicating potential for success in this intervention.
Eligibility criteria
Show full inclusion / exclusion 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.
Where this trial is running
Gothenburg
- University of Gothenburg — Gothenburg, Sweden (RECRUITING)
Study contacts
- Study coordinator: Theresa Westgård, PhD, Associate Professor
- Email: Theresa.westgard@neuro.gu.se
- Phone: 18628820334
How to participate
- Review the eligibility criteria above with your treating physician.
- Visit the official trial page on ClinicalTrials.gov for the most current contact information and recruitment status.
- Contact the listed study coordinator or principal investigator to request pre-screening. Pre-screening is free and never obligates you to enroll.
Conditions: Frailty, Dependence, Integrated Care, Person-centred care