Chronic Disease Clinical Trial
Official title:
Protocol for the Evaluation of Community-based Care for the Frail Elderly in Badalona Serveis Assistencials
The term frail chronic complex patient (CCP) is generally applied to subjects with
heterogeneous conditions that may represent at least one of the following three traits: (i)
the need for management by a number of specialists from different disciplines that often
leads to high use of healthcare resources; (ii) fragility, which requires additional support
either due to functional decline, social deficits and/or transient situations such as
hospital discharge or, (iii) the need for highly specialised care with home technological
support.
The current protocol deals with the second category of patients, frail CCP, and addresses
horizontal integration of community-based services. It is based in the city of Badalona (216K
inhabitants), within the metropolitan area of Barcelona. Badalona Serveis Assistencials (BSA)
is the service provider of integrated care services for this population.
The study will assess three types of specific groups of patients: (i) Early discharge group
includes patients acutely admitted to the medical and/or surgical hospital wards and promptly
discharged to receive home-based post-acute care and/or rehabilitation; (ii) Home-based Case
Management group includes complex chronic patients or patients receiving long-term care by a
case management nurse; and (iii) Geriatric residences group will include patients receiving
acute support, post-acute or continued care for elderly people living in geriatric
residences.
It will be conducted by Badalona Serveis Assistencials (BSA), an integrated care service
provider located in the city of Badalona (420K inhabitants) in the North-Eastern part of the
Barcelona Metropolitan Area.
The current study protocol aims to assess cost-effectiveness of the three types of
interventions for frail patients, as well as to generate a roadmap for regional scalability
of the service. The study design will consist of a prospective quasi-experimental
case-control design wherein each intervention group will be compared with the corresponding
usual care group (controls, 1:1 ratio), using propensity score matching. Age, sex, GMA
(adjusted morbidity groups), socioeconomic status, number of hospitalisations during the
previous year and polypharmacy will be used as matching variables.
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