Integrated Care Pathways in a Community Setting

Chronic Illness Clinical Trial

Official title:

Enabling Elderly Patients to Manage Their Own Lives - A Systematic Management Program for Home Care Services.

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT01107119
• Other study ID #: 21528
• Status: Completed
• Phase: N/A
• First received: April 18, 2010
• Last updated: April 19, 2017
• Start date: October 2009
• Est. completion date: October 2012

Study information

• Verified date: April 2017
• Source: Norwegian University of Science and Technology
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

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.

Description:

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.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 304
• Est. completion date: October 2012
• Est. primary completion date: March 2012
• Accepts healthy volunteers: No
• Gender: All
• Age group: 70 Years and older

Eligibility

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.

Related Conditions & MeSH terms

• Chronic Disease
• Chronic Illness

Intervention

Other:
• integrated care pathway
communication and follow-up program for integrated care
• usual care

Locations

Country	Name	City	State
Norway	Fræna Municpality	Fræna
Norway	Molde hospital	Molde
Norway	Orkdal Municipality	Orkdal
Norway	Sunndal Municiplaity	Sunndal
Norway	Surnadal Municipality	Surnadal
Norway	St Olav's University hospital	Trondheim
Norway	Trondheim municiplaity	Trondheim

Sponsors (9)

Lead Sponsor	Collaborator
Norwegian University of Science and Technology	City of Trondheim, Local authorities of Fræna, Local authorities of Orkdal, Local authorities of Sunndal, Local authorities of Surnadal, Nordmøre and Romsdal Hospital Trust, St. Olavs Hospital, The Research Council of Norway

Country where clinical trial is conducted

Norway, 

References & Publications (3)

Røsstad T, Garåsen H, Steinsbekk A, Håland 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 — View Citation

Røsstad T, Garåsen 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. — View Citation

Røsstad T, Salvesen Ø, Steinsbekk A, Grimsmo A, Sletvold O, Garåsen 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 — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	activities of daily living (ADL)	Individbasert pleie- og omsorgsstatistikk (IPLOS) scale, and Nottingham Extended ADL Scale	6 and 12 months
Primary	Institutional health care at primary and secondary level	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
Secondary	Achieve better collaboration within primary care and between primary- and secondary health care providers	Extract information on communication from EPJ municipal care and EPJ General practitioners	1 year