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Frail Elderly Patients clinical trials

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NCT ID: NCT02318680 Completed - Readmission Clinical Trials

Follow Home Visits After Discharge

Start date: January 2013
Phase: N/A
Study type: Interventional

The study aims to assess whether a follow home visit after discharge of frail elderly patients from Nykøbing Falster Hospital reduces the risk of readmission within 180 days. Staff from the hospital ward identifies patients fulfilling the inclusion criteria and refers the patients to two project nurses at the hospital (follow home team). One of the project nurses gets the informed consent from the patient, or in case of a patient who is not able to give informed consent, from the family and general practitioner. The patient is then randomized to intervention (follow home visit after discharge) or control. In the intervention group, the hospital project nurse and the patient meets with the municipal nurse in the patient's home on the same day the patient is being discharged from the hospital. During this visit the discharge from the hospital and the actual functioning of the patient in his own surroundings is reviewed, using a structured assessment.