Personalized, interdisziplinary patient pathway to cross-sector care of multimorbid patients
- Conditions
- I25I10I50J44N18E11E10I70.29Heart failureOther chronic obstructive pulmonary disease
- Registration Number
- DRKS00031500
- Lead Sponsor
- niversität zu Köln
- Brief Summary
Not available
- Detailed Description
Not available
Recruitment & Eligibility
- Status
- Recruiting
- Sex
- All
- Target Recruitment
- 946
Acute inpatient admission or transfer to a normal ward of a participating center due to an internal disease (initial admission diagnosis) in the form of:
o direct admission from home / from the referring resident HA / FA
o Transfer from the in-house emergency room
o Admission from an external hospital (reason for admission: internal medicine)
o Admission from another care unit within the hospital .
- Age = 55 years
- multimorbid patients (at least 3 diseases)
- At least one of the following index diagnoses:
o heart failure (HI) (NYHA I-IV)
o Renal insufficiency (NI)
o Chronic obstructive pulmonary disease (COPD)
o Diabetes mellitus (DM)
o Peripheral arterial occlusive disease (pAVK)
o Coronary heart disease (CHD)
o arterial hypertension
- High risk for unplanned readmission (risk assessment using Multidimensional Prognostic Index (MPI) = 0.34).
- Written consent, documented by signature, after adequate reflection time. Patient education and consent can only occur outside of an acute medical emergency situation.
- Patients with a non-internal medicine initial reason for admission (this includes the reason for admission for initial admission to an external hospital).
- Patients who can be discharged within a maximum of 2 working days
- Residents of nursing facilities, 24-hour home care, predominant bedriddenness
- lack of rehabilitation potential according to the assessment of the attending physician
- insufficient German language skills among patients and relatives / acquaintances
- higher degree of visual and/or hearing impairment
- illnesses with a life expectancy of less than 6 months
- desired rehabilitation on day 1 to 42 after discharge from index hospitalization
- distance to the patient's home of significant more than 50 km (individual decision)
- Persons who have private health insurance
- persons who are in a dependent/employed relationship with the investigators
- Lack of business and consent capacity
- Placement in an institution by court or official order
Study & Design
- Study Type
- observational
- Study Design
- Not specified
- Primary Outcome Measures
Name Time Method
- Secondary Outcome Measures
Name Time Method