Integrated Care Pathways in a Community Setting
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.
調査の概要
詳細な説明
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.
研究の種類
入学 (実際)
段階
- 適用できない
連絡先と場所
研究場所
-
-
-
Fræna、ノルウェー
- Fræna Municpality
-
Molde、ノルウェー
- Molde Hospital
-
Orkdal、ノルウェー
- Orkdal Municipality
-
Sunndal、ノルウェー
- Sunndal Municiplaity
-
Surnadal、ノルウェー
- Surnadal Municipality
-
Trondheim、ノルウェー、7006
- St Olav's University Hospital
-
Trondheim、ノルウェー
- Trondheim municiplaity
-
-
参加基準
適格基準
就学可能な年齢
健康ボランティアの受け入れ
受講資格のある性別
説明
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.
研究計画
研究はどのように設計されていますか？
デザインの詳細
- 主な目的：ヘルスサービス研究
- 割り当て：ランダム化
- 介入モデル：並列代入
- マスキング：なし（オープンラベル）
武器と介入
参加者グループ / アーム |
介入・治療 |
|---|---|
|
アクティブコンパレータ：普段のお手入れ
|
|
|
実験的：Integrated care pathway
program for
|
communication and follow-up program for integrated care
|
この研究は何を測定していますか？
主要な結果の測定
結果測定 |
メジャーの説明 |
時間枠 |
|---|---|---|
|
activities of daily living (ADL)
時間枠：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
時間枠：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
|
二次結果の測定
結果測定 |
メジャーの説明 |
時間枠 |
|---|---|---|
|
Achieve better collaboration within primary care and between primary- and secondary health care providers
時間枠：1 year
|
Extract information on communication from EPJ municipal care and EPJ General practitioners
|
1 year
|
協力者と研究者
協力者
捜査官
- 主任研究者：Anders Grimsmo, md phd、Norwegian University of Science and Technology
出版物と役立つリンク
一般刊行物
- Rosstad T, Garasen H, Steinsbekk A, Sletvold O, Grimsmo A. Development of a patient-centred care pathway across healthcare providers: a qualitative study. BMC Health Serv Res. 2013 Apr 1;13:121. doi: 10.1186/1472-6963-13-121.
- Rosstad T, Garasen H, Steinsbekk A, Haland E, Kristoffersen L, Grimsmo A. Implementing a care pathway for elderly patients, a comparative qualitative process evaluation in primary care. BMC Health Serv Res. 2015 Mar 4;15:86. doi: 10.1186/s12913-015-0751-1.
- Rosstad T, Salvesen O, Steinsbekk A, Grimsmo A, Sletvold O, Garasen H. Generic care pathway for elderly patients in need of home care services after discharge from hospital: a cluster randomised controlled trial. BMC Health Serv Res. 2017 Apr 17;17(1):275. doi: 10.1186/s12913-017-2206-3.
研究記録日
主要日程の研究
研究開始
一次修了 (実際)
研究の完了 (実際)
試験登録日
最初に提出
QC基準を満たした最初の提出物
最初の投稿 (見積もり)
学習記録の更新
投稿された最後の更新 (実際)
QC基準を満たした最後の更新が送信されました
最終確認日
詳しくは
この情報は、Web サイト clinicaltrials.gov から変更なしで直接取得したものです。研究の詳細を変更、削除、または更新するリクエストがある場合は、register@clinicaltrials.gov。 までご連絡ください。 clinicaltrials.gov に変更が加えられるとすぐに、ウェブサイトでも自動的に更新されます。