AdvantAGE: Implementation and Evaluation of an Interprofessional Tranistional Care Model for Frail Older Adults (AdvantAGE)

AdvantAGE: Implementation and Evaluation of an Interprofessional Transitional Care Model for Frail Older Adults at the University Department of Geriatric Medicine FELIX PLATTER

This clinical trial at the University Department of Geriatric Medicine FELIX Platter in Basel, Switzerland, is designed to evaluate a new transitional care model aimed at helping frail older adults after they get discharged from the hospital. The AdvantAGE study aims to explore the following questions:

• Does the new care model help reduce the number of patients who need to return to the hospital within 90 days?
• How effective is the implementation of this care model?

Participants in the trial will be followed by advanced practice nurses for up to 90 days after hospital discharge. The patients and their caregivers will receive support in coordinating care, managing medications, and learning to manage the patient's health conditions on their own. Additionally, they will have the opportunity to engage in discussions about advanced care planning.

Study Overview

• Status: Recruiting
• Conditions: Multimorbidity; Transitional Care; Geriatric Care
• Intervention / Treatment: Other: Transitional care model

• Study Type: Interventional
• Enrollment (Estimated): 250
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Mario Ernst; Phone Number: +41 61 326 44 81; Email: mario.ernst@felixplatter.ch
• Study Contact Backup: Name: Isabel Pfundstein; Phone Number: +41 61 326 44 81; Email: isabel.pfundstein@felixplatter.ch

Study Locations

• Switzerland
  • Basel, Switzerland, 4055
    • Recruiting
    • Universitäre Altersmedizin FELIX PLATTER
    • Contact: Mario Ernst, MSc; Phone Number: +41613264481; Email: mario.ernst@felixplatter.ch

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Currently admitted to the acute or rehabilitation ward of University Department of Geriatric Medicine
• Reside in Basel-Stadt
• Possess the ability to speak and comprehend the German language
• Scheduled to be discharged to their home
• 65 years or older
• Identified by a clinician as having a high risk of deterioration due to frailty

Additionally, participants must meet at least one of the following criteria:

• diagnosed with a complex chronic disease requiring support in self-management and disease management, or
• facing socially challenging situations such as living alone without a supportive network or lacking a GP, or
• admitted for an acute illness with a brief hospital stay (e.g., infection, cardiac decompensation) and need support in self- and disease management, and continuity of the therapy plan, including close monitoring.

Exclusion Criteria:

• residing in a nursing home or being newly admitted to one
• lacking informal caregivers and exhibiting severe cognitive impairment (MMS ≤23)
• scoring <50 on the motoric domain of the Functional Independence Measure (FIM)
• having a psychiatric disorder that significantly impacts their ability to manage daily life at time of the discharge

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm

Intervention / Treatment

Experimental: Intervention group; The intervention includes five core elements provided by a multiprofessional team: (1) continuous support for patients and caregivers; (2) care coordination with primary care providers;(3) visits at patients' homes; (4) medication- and self-management with patients and caregivers; and (5) proactive advanced care planning. Patients will receive specialized support including home visits up to 90 days after hospital discharge.

Other: Transitional care model; A newly developed care model to support frail older adults during their transition from hospital to home.; Other Names: AdvantAGE

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
90-days rehospitalization rate	Number of unplanned hospital admissions of any kind happening within 90 days after discharge	90 days post-discharge

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
30-days rehospitalization rate	Number of unplanned hospital admission of any kind happening within 30 days after discharge	30 days post-discharge
Time to readmission	Number of days between hospital discharge and unplanned hospital admission	Up to 90 days post-discharge
Number of emergency room visits	Number of emergency room visits (with or without hospital admission) within 90 days after discharge	90 days post-discharge
Time to emergency room visit	Number of days between hospital discharge and emergency room visit	Up to 90 days post-discharge
Patient's health-related quality of life	The EuroQoL-5D-5L is used to assess the health-related quality of life in patients at three time points. Prior to hospital discharge, 7 days and 90 days after hospital discharge or if the patient completed the intervention	Up to 90 days post-discharge
Patient satisfaction questionnaire	Satisfaction regarding intervention participation	up to 90 days post-discharge

Collaborators and Investigators

• Sponsor: Thekla Brunkert
• Collaborators: Health Department of the Canton of Basel-Stadt
• Investigators: Principal Investigator: Thekla Brunkert, PhD, Universitäre Altersmedizin FELIX PLATTER

Publications and helpful links

Helpful Links

• project homepage (in German)

Study record dates

Study Major Dates

• Study Start (Actual): January 8, 2024
• Primary Completion (Estimated): June 30, 2026
• Study Completion (Estimated): June 30, 2026

Study Registration Dates

• First Submitted: December 19, 2023
• First Submitted That Met QC Criteria: January 3, 2024
• First Posted (Actual): January 5, 2024

Study Record Updates

• Last Update Posted (Actual): February 2, 2024
• Last Update Submitted That Met QC Criteria: February 1, 2024
• Last Verified: February 1, 2024

More Information

Terms related to this study

• Keywords: Transitional Care, Frailty, Rehospitalisation, Geratric Care
• Additional Relevant MeSH Terms: Physiological Effects of Drugs; Neurotransmitter Agents; Molecular Mechanisms of Pharmacological Action; Cholinergic Agents; Imidacloprid
• Other Study ID Numbers: 02072

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