Optimising interprofessional communication in care provision for care-dependent people

Not Applicable

• Conditions: Basic population: care-dependent peopleDiseases investigated for the intensified monitoring: Diabetes mellitusDiseases investigated for the intensified monitoring: Heart failureDiseases investigated for the intensified monitoring:COPDDiseases investigated for the intensified monitoring: Par-kinson’s diseaseDiseases investigated for the intensified monitoring: Pain; E10-E14; I50; I11.0; I13.2; J44; G20; G21; G22; R52

• Registration Number: DRKS00026137
• Lead Sponsor: AOK Sachsen-Anhalt

Brief Summary

Not available

Detailed Description

Not available

Study Timeline

• Study Start: 2021-10-19
• Last Update Posted: 19 August 2024

Recruitment & Eligibility

• Status: Recruiting stopped after recruiting started
• Sex: All
• Target Recruitment: 95

Inclusion Criteria

General inclusion criteria:
People living in Sachsen-Anhalt can participate in the study. Patients can be included in the period 01.10.2021-30.09.2022.

Inclusion criteria communication with THP:
Care-dependent persons insured by AOK Sachsen-Anhalt or IKK gesund plus with a care dependence level of 2 or higher, who live in the project region in a nursing home according to §43 Social Code Book XI or receive ambulatory nursing care according to §36 Social Code Book XI and who agree to participate in the project.

Inclusion criteria intensive monitoring:
Insured persons of the aforementioned group with at least one of the following diseases or conditions: diabetes, heart failure, COPD, Parkinson's disease, pain and an increased need for monitoring in the case of an unstable state of illness at the instigation of the participating general practitioner.

Inclusion criteria control group:
Care-dependent persons insured by AOK Sachsen-Anhalt or IKK gesund plus with a care dependence level of 2 or higher, who live outside the project region (see Brief Summary in Lay Language) and at least one day during inclusion period in a nursing home according to §43 Social Code Book XI or receive ambulatory nursing care according to §36 Social Code Book XI.

Inclusion criteria care providers & general practitioners:
General practitioners who declared their participation in the special form of care, as well as outpatient care services and nursing homes in the project region that participate in the special form of care through cooperation agreements.

Exclusion Criteria

Insured persons with a care dependence level of 1 or no care dependence level or those who have chosen the cash benefit and/or use day or night care services.

Study & Design

• Study Type: interventional
• Study Design: Not specified

Primary Outcome Measures

Name	Time	Method
Rate of unplanned inpatient admissions. The primary end-point will be reviewed after the end of the intervention for the intervention period of 2 years (October 2021 – Sep-tember 2023). For this purpose, healthcare claims data from the participating health insurances will be used. Un-planned hospital admissions are identifiable via the admis-sion reason emergency.

Secondary Outcome Measures

Name	Time	Method
nplanned ambulatory care; Utilisation of the ambulance; Utilisation of cost-intensive unplanned health care in relation to utilisation of less cost-intensive unplanned health care; Mortality; Average total health care costs; Communication; Utilisation of the telehealth solution; Feasibility of the telehealth solution; Satisfaction <br>