Integrated Care Pathways in a Community Setting

April 19, 2017 updated by: Norwegian University of Science and Technology

Enabling Elderly Patients to Manage Their Own Lives - A Systematic Management Program for Home Care Services.

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.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

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 Type

Interventional

Enrollment (Actual)

304

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Norway
      • Fræna, Norway
        • Fræna Municpality
      • Molde, Norway
        • Molde Hospital
      • Orkdal, Norway
        • Orkdal Municipality
      • Sunndal, Norway
        • Sunndal Municiplaity
      • Surnadal, Norway
        • Surnadal Municipality
      • Trondheim, Norway, 7006
        • St Olav's University Hospital
      • Trondheim, Norway
        • Trondheim municiplaity

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

70 years and older (Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

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 Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Health Services Research
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Active Comparator: usual care
Other: usual care
Experimental: 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
Other: integrated care pathway
communication and follow-up program for integrated care

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
activities of daily living (ADL)
Time Frame: 6 and 12 months
Individbasert pleie- og omsorgsstatistikk (IPLOS) scale, and Nottingham Extended ADL Scale
6 and 12 months
Institutional health care at primary and secondary level
Time Frame: 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
1 year

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Achieve better collaboration within primary care and between primary- and secondary health care providers
Time Frame: 1 year
Extract information on communication from EPJ municipal care and EPJ General practitioners
1 year

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Norwegian University of Science and Technology

Collaborators

The Research Council of Norway
St. Olavs Hospital
Nordmøre and Romsdal Hospital Trust
City of Trondheim
Local authorities of Orkdal
Local authorities of Surnadal
Local authorities of Sunndal
Local authorities of Fræna

Investigators

  • Principal Investigator: Anders Grimsmo, md phd, Norwegian University of Science and Technology

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start

October 1, 2009

Primary Completion (Actual)

March 1, 2012

Study Completion (Actual)

October 1, 2012

Study Registration Dates

First Submitted

April 18, 2010

First Submitted That Met QC Criteria

April 19, 2010

First Posted (Estimate)

April 20, 2010

Study Record Updates

Last Update Posted (Actual)

April 20, 2017

Last Update Submitted That Met QC Criteria

April 19, 2017

Last Verified

April 1, 2017

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 21528

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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