AdvantAGE: Implementation and Evaluation of an Interprofessional Tranistional Care Model for Frail Older Adults

Not Applicable

Recruiting

• Conditions: Multimorbidity; Geriatric Care; Transitional Care
• Interventions: Other: Transitional care model

• Registration Number: NCT06190288
• Lead Sponsor: Thekla Brunkert

Brief Summary

This clinical trial at the University Department of Geriatric Medicine FELIX Platter in Basel, Switzerland, is designed to evaluate a new transitional care model aimed at helping frail older adults after they get discharged from the hospital. The AdvantAGE study aims to explore the following questions:

* Does the new care model help reduce the number of patients who need to return to the hospital within 90 days?

* How effective is the implementation of this care model?

Participants in the trial will be followed by advanced practice nurses for up to 90 days after hospital discharge. The patients and their caregivers will receive support in coordinating care, managing medications, and learning to manage the patient's health conditions on their own. Additionally, they will have the opportunity to engage in discussions about advanced care planning.

Detailed Description

Not available

Study Timeline

• Study First Submitted: 2023-12-19
• Study First Submitted QC: 2024-01-03
• Study First Posted: 2024-01-05
• Study Start: 2024-01-08
• Status Verified: 2024-02
• Last Update Submitted: 2024-02-01
• Last Update Posted: 2024-02-02
• Primary Completion: 2026-06-30
• Study Completion: 2026-06-30

Recruitment & Eligibility

• Status: RECRUITING
• Sex: All
• Target Recruitment: 250

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

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: SINGLE_GROUP

Arm && Interventions

Group	Intervention	Description
Intervention group	Transitional care model	The intervention includes five core elements provided by a multiprofessional team: (1) continuous support for patients and caregivers; (2) care coordination with primary care providers;(3) visits at patients' homes; (4) medication- and self-management with patients and caregivers; and (5) proactive advanced care planning. Patients will receive specialized support including home visits up to 90 days after hospital discharge.

Primary Outcome Measures

Name	Time	Method
90-days rehospitalization rate	90 days post-discharge	Number of unplanned hospital admissions of any kind happening within 90 days after discharge

Secondary Outcome Measures

Name	Time	Method
30-days rehospitalization rate	30 days post-discharge	Number of unplanned hospital admission of any kind happening within 30 days after discharge
Number of emergency room visits	90 days post-discharge	Number of emergency room visits (with or without hospital admission) within 90 days after discharge
Time to readmission	Up to 90 days post-discharge	Number of days between hospital discharge and unplanned hospital admission
Patient's health-related quality of life	Up to 90 days post-discharge	The EuroQoL-5D-5L is used to assess the health-related quality of life in patients at three time points. Prior to hospital discharge, 7 days and 90 days after hospital discharge or if the patient completed the intervention
Patient satisfaction questionnaire	up to 90 days post-discharge	Satisfaction regarding intervention participation
Time to emergency room visit	Up to 90 days post-discharge	Number of days between hospital discharge and emergency room visit

Trial Locations

Locations (1)

Universitäre Altersmedizin FELIX PLATTER; 🇨🇭 Basel, Switzerland