Enabling Elderly Patients to Manage Their Own Lives - A Systematic Management Program for Home Care Services.
试验速览
- 阶段
- 不适用
- 状态
- 已完成
- 入组人数
- 304
- 试验地点
- 7
- 主要终点
- Institutional health care at primary and secondary level
研究概览
简要总结
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.
详细描述
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.
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Parallel
- 主要目的
- Health Services Research
- 盲法
- None
入排标准
- 年龄范围
- 70 Years 至 —（Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •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.
排除标准
- •Do not agree or are not able to agree to participate
- •Is already involved in other research studies affecting the home care services.
研究组 & 干预措施
usual care
usual care
干预措施: usual care (Other)
Integrated care pathway
program for
- communication and information flow aimed at collaboration between hospitals, general practitioners and home care services
- systematic patient follow-up in home care services by using checklists
干预措施: integrated care pathway (Other)
结局指标
主要结局
Institutional health care at primary and secondary level
时间窗: 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)
时间窗: 6 and 12 months
Individbasert pleie- og omsorgsstatistikk (IPLOS) scale, and Nottingham Extended ADL Scale
次要结局
- Achieve better collaboration within primary care and between primary- and secondary health care providers(1 year)