Municipality-based Post-discharge Follow-up Visits

Frailty Clinical Trial

Official title:

Effect of Municipality-based Post-discharge Follow-up Visit Including the Primary Physician on Early Re-hospitalization in High Risk People of 65+ Years. A Randomised Controlled Trial.

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT02094040
• Other study ID #: 3800H0.52-0059
• Status: Completed
• Phase: N/A
• First received: March 12, 2014
• Last updated: March 19, 2014
• Start date: February 2012
• Est. completion date: December 2013

Study information

• Verified date: March 2014
• Source: Holbaek Sygehus
• Contact: n/a
• Is FDA regulated: No
• Health authority: Denmark: Danish Dataprotection Agency
• Study type: Interventional

Clinical Trial Summary

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.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 531
• Est. completion date: December 2013
• Est. primary completion date: December 2013
• Accepts healthy volunteers: No
• Gender: Both
• Age group: 65 Years and older

Eligibility

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.)

Study Design

Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Single Blind (Investigator), Primary Purpose: Prevention

Related Conditions & MeSH terms

• Frailty
• Primary Care
• Readmission
• Transition

Intervention

Behavioral:
• Receive municipality-based follow-up visit
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.

Locations

Country	Name	City	State
Denmark	Medicinsk Afdeling, Holbæk Sygehus	Holbæk

Sponsors (3)

Lead Sponsor	Collaborator
Holbaek Sygehus	Danish Institute for Public Health, Region Sjælland

Country where clinical trial is conducted

Denmark, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Other	Long-term death rate	Other pre-specified outcome concerns death rate measured at 30 and 180 days post discharge. Data is obtained from the official register of Danish patients (Landspatientregistret).	Within 180 days from discharge	Yes
Other	Long-term use of primary health care services	Other pre-specified outcome concerns the use of primary health care services measured at 30 and 180 days post discharge. Data is obtained from the official register of primary health care in Denmark (Sygesikringsregistret) and registration from 3 Danish municipalities.	Within 180 days from discharge	No
Other	Long-term use of secondary health care services	Other pre-specified outcome concerns the use of secondary health care services measured at 30 and 180 days post discharge. Data is obtained from the official register of Danish patients (Landspatientregistret).	Within 180 days from discharge	No
Primary	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).	Within 30 days from discharge	Yes
Secondary	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).	Within 180 days from discharge	Yes