Effect of a Transitional Care Intervention

Effect of a Transitional Care Intervention From Hospital to Home on Readmissions Among Older Medical Patients: a Quasi-experimental Study.

The objective of this study is to evaluate the effect of a transitional care intervention on readmissions among older medical patients.

The proportion of older people is rapidly growing. These changes represent a challenge for healthcare systems. 20% of all hospital admitted patients ≥ 65 years are readmitted within the first 30 days after discharge. Prior transitional care research has mainly focused on either hospital-based or community-based interventions with no or little intervention elements in both settings. The results show different effects on readmission rates. This calls for new research on trans-sectorial interventions with both pre- and post-discharge elements.

Study Overview

• Status: Completed
• Conditions: Frailty
• Intervention / Treatment: Other: Follow-Home-intervention

Detailed Description

Design:

Non-randomized controlled trial.

Participants For eligibility criteria - see elsewhere. Intervention group • Patients living in Odder, Skanderborg or Hedensted municipality

Control group

• Patients living in Horsens municipality

Follow-Home Intervention

The intervention group receives following intervention:

If possible, all included participants are physically followed home by a hospital-based project worker on the day of discharge. During the visit, the focus is on: basic human needs, medication review reconciliation, and a comprehensive geriatric assessment. Problems, challenges and concerns are discussed. Finally, a conference for the following working day is arranged either as a physical visit or a video conference. The patient, relatives, community-based nurse and project worker are invited to participate and health status and challenges are discussed They are recommended to contact the project worker about health and practical issues up to 7 days after discharge where the intervention ends. Subsequently, the responsibility for treatment and care is assigned to the GP and home healthcare provider.

Usual care

Patients in the control group recieves the following usual discharge procedure:

On the day of discharge, the hospital-based nurse digitally sends a summery of the hospital stay and a treatment and care plan to the community-based nurse. If needed, the hospital-based nurse contacts the community-based nurse by phone as a supplement to the plan. Finally, a discharge letter conducted by the hospital-based doctor is digitally sent to the GP.

Method:

Inclusion of participants is consecutive. Inclusion period was between 01/02/17 to 31/12/19. In total, approximately 1200 patients were included .

Data collection Outcome data will be retrieved from CROSS-TRACKS database at 30 days after discharge from index admission.

Analysis

Intervention and Control group will be matched on 3 variables on individual level:

• CCI
• Index admission period: +/- 3-4 weeks
• Sex

All readmissions are included in the analysis (not only first time readmissions). That means that one patient can be included several times.

Logistic regression adjusted for possible confounders will be used when analysing the outcomes. Confounders are chosen through a study specific DAG.

Sub-group analysis will be conducted according to:

• Age
• Sex
• Housing
• Civil status
• Social status
• Length of hospital stay in index admission
• Comorbidity
• Diagnosis
• Ect.

• Study Type: Interventional
• Enrollment (Actual): 1266
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Denmark
  • Horsens, Denmark, 8700
    • Horsens Regional Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 75 years and older (OLDER_ADULT)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Patients aged ≥75 years
• Living in the municipalities of Odder, Skanderborg, Hedensted or Horsens
• Admitted for ≥48 hours
• Discharged from Medical Ward 1 (MSA1) at Horsens Regional Hospital (HRH)

Exclusion Criteria:

• Terminally ill patients
• Patients with cerebrovascular events
• Readmitted to another hospital
• Not able to speak and understand Danish

Study Plan

How is the study designed?

Design Details

• Primary Purpose: PREVENTION
• Allocation: NON_RANDOMIZED
• Interventional Model: PARALLEL
• Masking: NONE

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
EXPERIMENTAL: Follow Home Intervention; If possible, all included participants are physically followed home by a hospital-based project worker on the day of discharge. During the visit, the focus is on: basic human needs, medication review reconciliation, and a comprehensive geriatric assessment. Problems, challenges and concerns are discussed. Finally, a conference for the following working day is arranged either as a physical visit or a video conference. The patient, relatives, community-based nurse and project worker are invited to participate and health status and challenges are discussed They are recommended to contact the project worker about health and practical issues up to 7 days after discharge where the intervention ends. Subsequently, the responsibility for treatment and care is assigned to the GP and home healthcare provider.	Other: Follow-Home-intervention; x
NO_INTERVENTION: Control; On the day of discharge, the hospital-based nurse digitally sends a summary of the hospital stay and a treatment and care plan to the community-based nurse. If needed, the hospital-based nurse contacts the community-based nurse by phone as a supplement to the plan. Finally, a discharge letter conducted by the hospital-based doctor is digitally sent to the GP

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Readmission	Unplanned all-cause readmission	Readmission will be assessed at 30 days after hospital discharge in both intervention and control group

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Mortality	All-cause mortality	Mortality will be assessed at 30 days after hospital discharge in both intervention and control group

Collaborators and Investigators

• Sponsor: University of Aarhus
• Investigators: Study Chair: Merete Gregersen, PHD, Aarhus University Hospital

Study record dates

Study Major Dates

• Study Start (ACTUAL): February 1, 2017
• Primary Completion (ACTUAL): December 31, 2019
• Study Completion (ACTUAL): December 31, 2019

Study Registration Dates

• First Submitted: February 24, 2021
• First Submitted That Met QC Criteria: March 10, 2021
• First Posted (ACTUAL): March 15, 2021

Study Record Updates

• Last Update Posted (ACTUAL): November 4, 2021
• Last Update Submitted That Met QC Criteria: October 27, 2021
• Last Verified: February 1, 2021

More Information

Terms related to this study

• Keywords: discharge; readmission; transitional care; older medical patients
• Additional Relevant MeSH Terms: Pathologic Processes; Frailty
• Other Study ID Numbers: FH2017-2019

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No