Transsectoral Intervention Program for Improvement of Geriatric Care in Regensburg
试验速览
- 阶段
- 不适用
- 状态
- 已完成
- 发起方
- 入组人数
- 252
- 试验地点
- 4
- 主要终点
- Readmission Rate
研究概览
简要总结
The aim of the transsectoral care project TIGER is the reduction of readmission rates of geriatric patients. This aim shall be achieved by improving the hitherto inadequate care process for geriatric patients in the transition from hospital to home. The program offers substantial support of patients and their informal caregivers in the transition process from hospital to home via so called pathfinders, specialized nurses in geriatrics.The pathfinders effectively intertwine stationary and ambulatory care teams caring for a patient, thereby augmenting and complementing effective hospital release management.
详细描述
Especially for older, chronically ill persons, a hospital stay can promote significant losses in functionality, independence and quality of life, and can increase nutrition deficits and the risk for infections, leading to the occurrence of severe gaps in care after hospital release and to an increased risk for readmission rates.
Even if the German government has recognized the necessity of a multiprofessional integrated care program for older, vulnerable patients and has installed a hospital release management program situated in hospitals in 2012, clarifying entitlements to benefits and setting up ambulatory services contacts, this does not yet meet the complex needs of geriatric patients and their informal caregivers.
Internationally, the Transitional Care Model (TCM) has been developed (M. Naylor et al. 1994) to address the deficits in care of older patients in transition between hospital to home. Via a series of defined activities, a disruption of the care supply chain for older patients in this transition process is being avoided.
The TIGER program will address the needs of geriatric patients and their informal caregivers and will support them via structured continuous activities, on the basis of the TCM, by so called pathfinders, nurses specialized in geriatrics. These pathfinders will develop an individual care plan with the patients, their informal caregivers and the hospital physicians already inside the hospital setting and will then develop and improve this further during up to twelve months after the hospital release of the patient. The pathfinders will coordinate the ambulatory care team services and closely involve the primary physicians. The patients and their informal caregivers will be empowered and educated to achieve a stabilization or improvement in functionality, independence, quality of life, coping with disease, nutritional status and wound healing process of the patients.
The aim of the program is that these activities will lead to a reduction of necessary readmission rates of geriatric patients.
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Parallel
- 主要目的
- Supportive Care
- 盲法
- None
盲法说明
The patients data will be anonymized and entered into an electronic Case Report form. The Outcomes Assessor will only see the anonymized data.
入排标准
- 年龄范围
- 75 Years 至 —（Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •will go back home after Hospital stay, AOK Patient, MiniMentalStateExamination MMSE score of at least 22, is living within 50 km range of the hospital
排除标准
- •palliative status, planned readmission into hospital within next 4 weeks
结局指标
主要结局
Readmission Rate
时间窗: up to 12 months
The number of readmissions of a patient into a hospital within up to 15 months (study period for the patient.plus 3 months prior to enrollment).
次要结局
- Cognitive Status - 2(up to 12 months)
- Functionality and mobility - 1(up to 12 months)
- Functionality and mobility - 2(up to 12 months)
- Functionality and mobility - 3(up to 12 months)
- Depression(up to 12 months)
- Burden of informal caregivers - 2(up to 12 months)
- Functionality and mobility - 5(up to 12 months)
- Nutritional status(up to 12 months)
- Cognitive Status - 1(up to 12 months)
- Care situation, care supply and quality of care at home(up to 12 months)
- Functionality and mobility - 4(up to 12 months)
- Health-related quality of life(up to 12 months)
- Burden of informal caregivers - 1(up to 12 months)
- Transfers into nursing homes(Up to 12 months)