Effect of Municipality-based Post-discharge Follow-up Visit Including the Primary Physician on Early Re-hospitalization in High Risk People of 65+ Years. A Randomised Controlled Trial.

Holbaek Sygehus1 site in 1 country531 target enrollmentFebruary 2012

ConditionsFrailty Readmission Transition Primary Care

Overview

Phase: Not Applicable
Intervention: Not specified
Conditions: Frailty
Sponsor: Holbaek Sygehus
Enrollment: 531
Locations: 1
Primary Endpoint: Re-admission
Status: Completed
Last Updated: 12 years ago

Overview Investigators Eligibility Criteria Outcomes Sites Similar Trials

Overview

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.

Registry

clinicaltrials.gov

Start Date

February 2012

End Date

December 2013

Last Updated

12 years ago

Study Type

Interventional

Study Design

Parallel

Sex

All

Investigators

Sponsor

Holbaek Sygehus

Responsible Party

Sponsor

Eligibility Criteria

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.)

Outcomes

Primary Outcomes

Re-admission

Time Frame: 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).