AdvantAGE: Implementation and Evaluation of an Interprofessional Tranistional Care Model for Frail Older Adults

Multimorbidity Clinical Trial

— AdvantAGE  

Official title:

AdvantAGE: Implementation and Evaluation of an Interprofessional Transitional Care Model for Frail Older Adults at the University Department of Geriatric Medicine FELIX PLATTER

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT06190288
• Other study ID #: 02072
• Status: Recruiting
• Phase: N/A
• Start date: January 8, 2024
• Est. completion date: June 30, 2026

Study information

• Verified date: February 2024
• Source: University Department of Geriatric Medicine FELIX PLATTER
• Contact: Mario Ernst
• Phone: +41 61 326 44 81
• Email: mario.ernst[@]felixplatter.ch
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

This clinical trial at the University Department of Geriatric Medicine FELIX Platter in Basel, Switzerland, is designed to evaluate a new transitional care model aimed at helping frail older adults after they get discharged from the hospital. The AdvantAGE study aims to explore the following questions: - Does the new care model help reduce the number of patients who need to return to the hospital within 90 days? - How effective is the implementation of this care model? Participants in the trial will be followed by advanced practice nurses for up to 90 days after hospital discharge. The patients and their caregivers will receive support in coordinating care, managing medications, and learning to manage the patient's health conditions on their own. Additionally, they will have the opportunity to engage in discussions about advanced care planning.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 250
• Est. completion date: June 30, 2026
• Est. primary completion date: June 30, 2026
• Accepts healthy volunteers: No
• Gender: All
• Age group: 65 Years and older

Eligibility

Inclusion Criteria:

• Currently admitted to the acute or rehabilitation ward of University Department of Geriatric Medicine
• Reside in Basel-Stadt
• Possess the ability to speak and comprehend the German language
• Scheduled to be discharged to their home
• 65 years or older
• Identified by a clinician as having a high risk of deterioration due to frailty

Additionally, participants must meet at least one of the following criteria:

• diagnosed with a complex chronic disease requiring support in self-management and disease management, or
• facing socially challenging situations such as living alone without a supportive network or lacking a GP, or
• admitted for an acute illness with a brief hospital stay (e.g., infection, cardiac decompensation) and need support in self- and disease management, and continuity of the therapy plan, including close monitoring.

Exclusion Criteria:

• residing in a nursing home or being newly admitted to one
• lacking informal caregivers and exhibiting severe cognitive impairment (MMS =23)
• scoring <50 on the motoric domain of the Functional Independence Measure (FIM)
• having a psychiatric disorder that significantly impacts their ability to manage daily life at time of the discharge

Related Conditions & MeSH terms

• Multimorbidity
• Transitional Care

Intervention

Other:
• Transitional care model
A newly developed care model to support frail older adults during their transition from hospital to home.

Locations

Country	Name	City	State
Switzerland	Universitäre Altersmedizin FELIX PLATTER	Basel

Sponsors (2)

Lead Sponsor	Collaborator
Thekla Brunkert	Health Department of the Canton of Basel-Stadt

Country where clinical trial is conducted

Switzerland, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	90-days rehospitalization rate	Number of unplanned hospital admissions of any kind happening within 90 days after discharge	90 days post-discharge
Secondary	30-days rehospitalization rate	Number of unplanned hospital admission of any kind happening within 30 days after discharge	30 days post-discharge
Secondary	Time to readmission	Number of days between hospital discharge and unplanned hospital admission	Up to 90 days post-discharge
Secondary	Number of emergency room visits	Number of emergency room visits (with or without hospital admission) within 90 days after discharge	90 days post-discharge
Secondary	Time to emergency room visit	Number of days between hospital discharge and emergency room visit	Up to 90 days post-discharge
Secondary	Patient's health-related quality of life	The EuroQoL-5D-5L is used to assess the health-related quality of life in patients at three time points. Prior to hospital discharge, 7 days and 90 days after hospital discharge or if the patient completed the intervention	Up to 90 days post-discharge
Secondary	Patient satisfaction questionnaire	Satisfaction regarding intervention participation	up to 90 days post-discharge

External Links

•   project homepage (in German)