Municipality-based Post-discharge Follow-up Visits

Not Applicable

Completed

• Conditions: Frailty; Transition; Readmission; Primary Care
• Interventions: Behavioral: Receive municipality-based follow-up visit

• Registration Number: NCT02094040
• Lead Sponsor: Holbaek Sygehus

Brief Summary

The purpose of this study is to determine whether discharge follow-up visit by primary physician and community-based nurse affects the risk of early re-hospitalisation among high risk older people discharged from a medical ward.

Detailed Description

Not available

Study Timeline

• Study Start: 2012-02
• Primary Completion: 2013-12
• Study Completion: 2013-12
• Status Verified: 2014-03
• Study First Submitted: 2014-03-12
• Study First Submitted QC: 2014-03-19
• Last Update Submitted: 2014-03-19
• Study First Posted: 2014-03-21
• Last Update Posted: 2014-03-21

Recruitment & Eligibility

• Status: COMPLETED
• Sex: All
• Target Recruitment: 531

Inclusion Criteria

• Patient geography (The participant live in; Holbæk Kommune, Odsherred Kommune or Kalundborg Kommune.)
• Discharged from medical ward Holbæk Sygehus.
• Frailty (Rated by following criterion: dementia or a minimum of two of the following conditions; two or more hospitalisations within 12 month prior to follow up, los of physical function, treatment of two or more concurrent medical and/or surgical conditions, psychiatric disease, multi-pharmacy of more than 6 prescription medication, suspicious of congenital disturbances, substance abuse problem, disadvantaged social network, need for increasing home care following index hospitalization.)

Exclusion Criteria

• Not discharged to home (If the patient are not discharged to home.)
• No written consent (If the patient does not wish to participate / written consent are not signed.)

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Follow-up visit	Receive municipality-based follow-up visit	Receive municipality-based follow-up visit including primary physician.

Primary Outcome Measures

Name	Time	Method
Re-admission	Within 30 days from discharge	The primary outcome is re-hospitalisation rate within 30 days from discharge. Data is obtained from the official register of danish patients (Landspatientregistret).

Secondary Outcome Measures

Name	Time	Method
Long-term hospitalization rate	Within 180 days from discharge	Secondary outcome concerns hospitalization rate measured at 30 and 180 days post discharge. Data is obtained from the official register of Danish patients (Landspatientregistret).

Trial Locations

Locations (1)

Medicinsk Afdeling, Holbæk Sygehus; 🇩🇰 Holbæk, Denmark