Improvement of Transition From Hospital to Home for Older Patients in Germany
- Conditions
- Geriatric Patients in the Transition From Hospital to Home
- Interventions
- Behavioral: Pathfinder support
- Registration Number
- NCT03513159
- Lead Sponsor
- University of Erlangen-Nürnberg Medical School
- Brief Summary
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.
- Detailed Description
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.
Efficacy, practicability, and limitations of the program will be evaluated scientifically and economically and will be analyzed for a possible saving of costs for the health care system.
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 252
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
palliative status, planned readmission into hospital within next 4 weeks
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Pathfinder support Pathfinder support Pathfinder support with development of an individual care plan for the intervention patients and their informal caregivers, with the hospital physicians already inside the hospital setting. This will then be developed and improved further during up to twelve months after hospital release with the primary physician. 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. In the regular assessments they will be tested for functionality and nutritional parameters, quality of life and stress scores.
- Primary Outcome Measures
Name Time Method Readmission Rate 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).
- Secondary Outcome Measures
Name Time Method Cognitive Status - 2 up to 12 months Trail Making Test A\&B in seconds
Functionality and mobility - 1 up to 12 months Timed up and Go in seconds
Functionality and mobility - 2 up to 12 months Instrumental activities of daily living (IADL) in scale
Functionality and mobility - 3 up to 12 months handgrip strength in kilogramms
Depression up to 12 months Measured by Geriatric Depression Scale (GDS) in scale
Burden of informal caregivers - 2 up to 12 months Perceived Stress Questionnaire (PSQ)-questionnaires in scale
Functionality and mobility - 5 up to 12 months Short physical performance battery (SPPB) in scale
Nutritional status up to 12 months measured bei Mini Nutritional Assessment (MNA)
Cognitive Status - 1 up to 12 months Measured by Mini-Mental State Examination (MMSE) in scale
Care situation, care supply and quality of care at home up to 12 months Measured by Neues BegutAchtungsinstrument (NBA, Buscher, Wingenfeld \& Schaeffer, 2011) as scale
Functionality and mobility - 4 up to 12 months pedometer activPAL3 micro
Health-related quality of life up to 12 months Measured by Short-Form-Health Survey (SF-12) questionnaire in scale
Burden of informal caregivers - 1 up to 12 months Measured by Zarith-questionnaires in scale
Transfers into nursing homes Up to 12 months Comparison between intervention and control group. Data made available by cooperating partner Allgemeine Ortskrankenkasse (AOK) sickness fund in percent
Trial Locations
- Locations (2)
Institute for Biomedicine of Aging, University of Erlangen-Nürnberg
🇩🇪Nürnberg, Germany
Hospital of the Order of St.John of God Regensburg
🇩🇪Regensburg, Bavaria, Germany