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.
研究概览
详细说明
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.
研究类型
注册 (实际的)
阶段
- 不适用
联系人和位置
学习地点
-
-
-
Fræna、挪威
- Fræna Municpality
-
Molde、挪威
- Molde Hospital
-
Orkdal、挪威
- Orkdal Municipality
-
Sunndal、挪威
- Sunndal Municiplaity
-
Surnadal、挪威
- Surnadal Municipality
-
Trondheim、挪威、7006
- St Olav's University Hospital
-
Trondheim、挪威
- Trondheim municiplaity
-
-
参与标准
资格标准
适合学习的年龄
接受健康志愿者
有资格学习的性别
描述
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.
学习计划
研究是如何设计的？
设计细节
- 主要用途：卫生服务研究
- 分配：随机化
- 介入模型：并行分配
- 屏蔽：无（打开标签）
武器和干预
参与者组/臂 |
干预/治疗 |
|---|---|
|
有源比较器：日常护理
|
|
|
实验性的：Integrated care pathway
program for
|
communication and follow-up program for integrated care
|
研究衡量的是什么？
主要结果指标
结果测量 |
措施说明 |
大体时间 |
|---|---|---|
|
activities of daily living (ADL)
大体时间：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
大体时间：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
|
次要结果测量
结果测量 |
措施说明 |
大体时间 |
|---|---|---|
|
Achieve better collaboration within primary care and between primary- and secondary health care providers
大体时间：1 year
|
Extract information on communication from EPJ municipal care and EPJ General practitioners
|
1 year
|
合作者和调查者
合作者
调查人员
- 首席研究员：Anders Grimsmo, md phd、Norwegian University of Science and Technology
出版物和有用的链接
一般刊物
- 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.
研究记录日期
研究主要日期
学习开始
初级完成 (实际的)
研究完成 (实际的)
研究注册日期
首次提交
首先提交符合 QC 标准的
首次发布 (估计)
研究记录更新
最后更新发布 (实际的)
上次提交的符合 QC 标准的更新
最后验证
更多信息
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