Personalized, interdisziplinary patient pathway to cross-sector care of multimorbid patients - eliPfad

niversität zu Köln0 个研究点目标入组 946 人开始时间: 2023年8月14日最近更新: 2024年8月19日

适应症

试验速览

暂无简介。

•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

发起方

niversität zu Köln