New care model for frail older adults after hospital discharge
AdvantAGE: Implementation and Evaluation of an Interprofessional Transitional Care Model for Frail Older Adults at the University Department of Geriatric Medicine FELIX PLATTER
This study is testing a new support program for frail older adults after they leave the hospital to see if it helps them stay healthy and avoid going back to the hospital within 90 days.
Quick facts
| Phase | Not applicable |
|---|---|
| Study type | Interventional |
| Enrollment | 250 (estimated) |
| Ages | 65 Years and up |
| Sex | All |
| Sponsor | University Department of Geriatric Medicine FELIX PLATTER Academic / other |
| Locations | 1 site (Basel) |
| Trial ID | NCT06190288 on ClinicalTrials.gov |
What this trial studies
This clinical trial at the University Department of Geriatric Medicine FELIX Platter in Basel, Switzerland, evaluates a transitional care model designed to support frail older adults post-hospital discharge. The AdvantAGE study aims to determine if this model can reduce hospital readmissions within 90 days and assess its implementation effectiveness. Participants will receive assistance from advanced practice nurses for up to 90 days, focusing on care coordination, medication management, and health condition self-management, along with discussions on advanced care planning.
Who should consider this trial
Good fit: Ideal candidates are frail older adults aged 65 and above, residing in Basel-Stadt, who are at high risk of deterioration and scheduled for discharge to their home.
Not a fit: Patients residing in nursing homes or those without informal caregivers may not benefit from this study.
Why it matters
Potential benefit: If successful, this model could significantly reduce hospital readmissions and improve the quality of life for frail older adults.
How similar studies have performed: Other studies have shown success with transitional care models for older adults, indicating potential for positive outcomes in this approach.
Eligibility criteria
Show full inclusion / exclusion 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
Where this trial is running
Basel
- Universitäre Altersmedizin FELIX PLATTER — Basel, Switzerland (Recruiting)
Study contacts
- Principal investigator: Thekla Brunkert, PhD — Universitäre Altersmedizin FELIX PLATTER
- Study coordinator: Mario Ernst
- Email: mario.ernst@felixplatter.ch
- Phone: +41 61 326 44 81
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.