Integrated Care Pathways in a Community Setting

Not Applicable

Completed

• Conditions: Chronic Illness
• Interventions: Other: integrated care pathway; Other: usual care

• Registration Number: NCT01107119
• Lead Sponsor: Norwegian University of Science and Technology

Brief Summary

The ambition of this study is to raise the quality of care for old and chronically ill patients by establishing a sustainable, systematic prevention and integrated care model for users of home care services.

In this cluster randomized study the intervention will be carried through in five municipalities and three general hospitals. The home care units in every municipality will be randomized to either intervention og control units.

Detailed Description

The primary objective of this study is to develop a functional and integrated care model between primary and secondary health care that will meet the needs both in the city and in smaller rural areas.

The secondary objective of this study is to reduce the need of care at primary and secondary level through a a systematic and integrated follow-up by home care nurses and general practitioners to:

* Enable these patients to manage their health needs more efficiently and independently

* Achieve better collaboration within primary care

* Achieve better collaboration between primary- and secondary health care professionals

* Achieve increased satisfaction and confidence with the health care services by the users and their relatives both for included patients and other patients receiving home care services.

* Promote health and prevent unnecessary decline in health

* Strengthen the patients' ability to manage their daily activities.

Study Timeline

• Study Start: 2009-10
• Study First Submitted: 2010-04-18
• Study First Submitted QC: 2010-04-19
• Study First Posted: 2010-04-20
• Primary Completion: 2012-03
• Study Completion: 2012-10
• Status Verified: 2017-04
• Last Update Submitted: 2017-04-19
• Last Update Posted: 2017-04-20

Recruitment & Eligibility

• Status: COMPLETED
• Sex: All
• Target Recruitment: 304

Inclusion Criteria

• Person 70 years or above being discharged from the general hospital
• Will receive home care services within four weeks after being discharges from the hospital.

Exclusion Criteria

• Do not agree or are not able to agree to participate
• Is already involved in other research studies affecting the home care services.

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Integrated care pathway	integrated care pathway	program for 1. communication and information flow aimed at collaboration between hospitals, general practitioners and home care services 2. systematic patient follow-up in home care services by using checklists
usual care	usual care	usual care

Primary Outcome Measures

Name	Time	Method
Institutional health care at primary and secondary level	1 year	Readmission (30 days)and inpatient hospital stays, number and length of stay (EPJ hospitals) Number and length of stay in municipal nursing homes (EPJ municipals) Days before permanent stay in municipal nursing homes
activities of daily living (ADL)	6 and 12 months	Individbasert pleie- og omsorgsstatistikk (IPLOS) scale, and Nottingham Extended ADL Scale

Secondary Outcome Measures

Name	Time	Method
Achieve better collaboration within primary care and between primary- and secondary health care providers	1 year	Extract information on communication from EPJ municipal care and EPJ General practitioners

Trial Locations

Locations (7)

Surnadal Municipality; 🇳🇴 Surnadal, Norway

Fræna Municpality; 🇳🇴 Fræna, Norway

Orkdal Municipality; 🇳🇴 Orkdal, Norway

Sunndal Municiplaity; 🇳🇴 Sunndal, Norway

St Olav's University hospital; 🇳🇴 Trondheim, Norway

Trondheim municiplaity; 🇳🇴 Trondheim, Norway

Molde hospital; 🇳🇴 Molde, Norway