Municipality-based Post-discharge Follow-up Visits

N/ACompletedNCT02094040

Holbaek Sygehus531 enrolled

Overview

The purpose of this study is to determine whether discharge follow-up visit by primary physician and community-based nurse affects the risk of early re-hospitalisation among high risk older people discharged from a medical ward.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

PREVENTION

Masking

SINGLE

Enrollment

531

Conditions

Frailty Readmission Transition Primary Care

Interventions

Receive municipality-based follow-up visitBEHAVIORAL

Systematic electronic referral from hospital to municipality of high risk people at discharge from a medical ward. Contact from municipality service to primary physician and citizen, to arrange first home visit within 7 days with focus on: medication, rehabilitation plan and health care appointments, functional level and need for further health care initiatives. The visit is concluded by planning of further visits (up till tree) and division of responsibilities between primary physician and the municipality service.

Eligibility

Sex: ALLMin age: 65 Years

Medical Language ↔ Plain English

Inclusion Criteria: * Patient geography (The participant live in; Holbæk Kommune, Odsherred Kommune or Kalundborg Kommune.) * Discharged from medical ward Holbæk Sygehus. * Frailty (Rated by following criterion: dementia or a minimum of two of the following conditions; two or more hospitalisations within 12 month prior to follow up, los of physical function, treatment of two or more concurrent medical and/or surgical conditions, psychiatric disease, multi-pharmacy of more than 6 prescription medication, suspicious of congenital disturbances, substance abuse problem, disadvantaged social network, need for increasing home care following index hospitalization.) Exclusion Criteria: * Not discharged to home (If the patient are not discharged to home.) * No written consent (If the patient does not wish to participate / written consent are not signed.)

Locations (1)

Medicinsk Afdeling, Holbæk Sygehus

Holbæk, Denmark

Outcomes

Primary Outcomes

Re-admission

The primary outcome is re-hospitalisation rate within 30 days from discharge. Data is obtained from the official register of danish patients (Landspatientregistret).

Time frame: Within 30 days from discharge

Secondary Outcomes

Long-term hospitalization rate

Secondary outcome concerns hospitalization rate measured at 30 and 180 days post discharge. Data is obtained from the official register of Danish patients (Landspatientregistret).

Time frame: Within 180 days from discharge

Data from ClinicalTrials.gov

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