Improvement of transitional care from hospital to home for older patients, the TIGER study: protocol of a randomised controlled trial

Martina Rimmele, Jenny Wirth, Sabine Britting, Thomas Gehr, Margit Hermann, Dirk van den Heuvel, Andreas Kestler, Thomas Koch, Oliver Schoeffski, Dorothee Volkert, Klaus Wingenfeld, Susanne Wurm, Ellen Freiberger, Cornel Sieber, TIGER consortium, Martina Rimmele, Jenny Wirth, Sabine Britting, Thomas Gehr, Margit Hermann, Dirk van den Heuvel, Andreas Kestler, Thomas Koch, Oliver Schoeffski, Dorothee Volkert, Klaus Wingenfeld, Susanne Wurm, Ellen Freiberger, Cornel Sieber, TIGER consortium

Abstract

Introduction: In Germany, an efficient and feasible transition from hospital to home for older patients, ensuring continuous care across healthcare settings, has not yet been applied and evaluated. Based on the transitional care model (TCM), this study aims to reduce preventable readmissions of patients ≥75 years of age with a transitional care intervention performed by geriatric-experienced care professionals. The study investigates whether the intervention ensures continuous care during transition and stabilises the care situation of patients at home.

Methods and analyses: Randomised controlled clinical trial, recruiting between 25 April 2018 and 31 December 2019 in one German hospital in the city of Regensburg. The intervention group is supported by care professionals in the transition process from hospital to home for up to 12 months. Based on TCM, the intervention includes an individual care plan according to a patient's symptoms, risks, needs and values. The plan is advanced in the domestic situation via personal visits and telephone contacts. All necessary care actions regarding, for example, mobility, residence adjustments, or nutrition, are initiated to be executed by ambulant care services, and are monitored, evaluated and adapted if necessary. In supervising the care plan, the care professionals do not administer active care services themselves but coordinate them. Patients and their caregivers are actively engaged in the care planning and execution. In contrast, the control group receives only usual discharge planning in the hospital and usual ambulatory care.The primary outcome is the all-cause readmission rate assessed using health insurance data within a follow-up of up to 12 months after hospital discharge. Secondary outcomes include care quality, mobility, nutritional and wound situation, and health-related quality of life. They are assessed at baseline, after 1 month, 3 months, 6 months, and at the end of study visit. Additionally, the economic efficiency of the intervention will be evaluated.

Ethics and dissemination: Ethics approval for the trial was obtained from the Ethics Committee of the Friedrich-Alexander-Universität Erlangen-Nürnberg. Results will be published in peer-reviewed, open-access scientific journals and disseminated at national and international research conferences and through public presentations in the geriatric and healthcare community.

Trial registration: ClinicalTrials.gov identifier: NCT03513159.

Keywords: clinical trials; geriatric medicine; internal medicine; public health; quality in health care; risk management.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Study design. MMSE, Mini-Mental State Examination; NBA, Neues Begutachtungs Assessment, an assessment to determine eligibility for benefits from the long-term care insurance in Germany; TIGER, Transsectoral Intervention Programme for Improvement of Geriatric Care in Regensburg
Figure 2
Figure 2
Timeline of overall TIGER project. eCRF, electronic case report form; TIGER, Transsectoral Intervention Programme for Improvement of Geriatric Care in Regensburg.

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