Improvement of Transition From Hospital to Home for Older Patients in Germany

Geriatric Patients in the Transition From Hospital to Home Clinical Trial

— TIGER  

Official title:

Transsectoral Intervention Program for Improvement of Geriatric Care in Regensburg

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT03513159
• Other study ID #: IBA-2018-TIGER
• Status: Completed
• Phase: N/A
• Start date: April 25, 2018
• Est. completion date: February 28, 2021

Study information

• Verified date: March 2021
• Source: University of Erlangen-Nürnberg Medical School
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The aim of the transsectoral care project TIGER is the reduction of readmission rates of geriatric patients. This aim shall be achieved by improving the hitherto inadequate care process for geriatric patients in the transition from hospital to home. The program offers substantial support of patients and their informal caregivers in the transition process from hospital to home via so called pathfinders, specialized nurses in geriatrics.The pathfinders effectively intertwine stationary and ambulatory care teams caring for a patient, thereby augmenting and complementing effective hospital release management.

Description:

Especially for older, chronically ill persons, a hospital stay can promote significant losses in functionality, independence and quality of life, and can increase nutrition deficits and the risk for infections, leading to the occurrence of severe gaps in care after hospital release and to an increased risk for readmission rates.

Even if the German government has recognized the necessity of a multiprofessional integrated care program for older, vulnerable patients and has installed a hospital release management program situated in hospitals in 2012, clarifying entitlements to benefits and setting up ambulatory services contacts, this does not yet meet the complex needs of geriatric patients and their informal caregivers.

Internationally, the Transitional Care Model (TCM) has been developed (M. Naylor et al. 1994) to address the deficits in care of older patients in transition between hospital to home. Via a series of defined activities, a disruption of the care supply chain for older patients in this transition process is being avoided.

The TIGER program will address the needs of geriatric patients and their informal caregivers and will support them via structured continuous activities, on the basis of the TCM, by so called pathfinders, nurses specialized in geriatrics. These pathfinders will develop an individual care plan with the patients, their informal caregivers and the hospital physicians already inside the hospital setting and will then develop and improve this further during up to twelve months after the hospital release of the patient. The pathfinders will coordinate the ambulatory care team services and closely involve the primary physicians. The patients and their informal caregivers will be empowered and educated to achieve a stabilization or improvement in functionality, independence, quality of life, coping with disease, nutritional status and wound healing process of the patients.

The aim of the program is that these activities will lead to a reduction of necessary readmission rates of geriatric patients.

Efficacy, practicability, and limitations of the program will be evaluated scientifically and economically and will be analyzed for a possible saving of costs for the health care system.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 252
• Est. completion date: February 28, 2021
• Est. primary completion date: June 30, 2020
• Accepts healthy volunteers: No
• Gender: All
• Age group: 75 Years and older

Eligibility

Inclusion Criteria:

will go back home after Hospital stay, AOK Patient, MiniMentalStateExamination MMSE score of at least 22, is living within 50 km range of the hospital

Exclusion Criteria:

palliative status, planned readmission into hospital within next 4 weeks

Related Conditions & MeSH terms

• Geriatric Patients in the Transition From Hospital to Home

Intervention

Behavioral:
• Pathfinder support
A pathfinder will support the patient with structured activities.

Locations

Country	Name	City	State
Germany	Institute for Biomedicine of Aging, University of Erlangen-Nürnberg	Nürnberg
Germany	Hospital of the Order of St.John of God Regensburg	Regensburg	Bavaria

Sponsors (9)

Lead Sponsor

Collaborator

University of Erlangen-Nürnberg Medical School

AOK Health Insurance Bavaria, Federal Association for Geriatrics, Germany, Federal Joint Committee, German, Friedrich-Alexander-Universität Erlangen-Nürnberg, Hospital of the Order of St.John of God Regensburg, Barmherzige Brueder, Germany, Institute for Community Medicine, University of Greifswald, Germany, Institute for Nursing Sciences, University of Bielefeld, Germany, Regensburg Physicians Network RAEN

Country where clinical trial is conducted

Germany, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Readmission Rate	The number of readmissions of a patient into a hospital within up to 15 months (study period for the patient.plus 3 months prior to enrollment).	up to 12 months
Secondary	Functionality and mobility - 1	Timed up and Go in seconds	up to 12 months
Secondary	Functionality and mobility - 2	Instrumental activities of daily living (IADL) in scale	up to 12 months
Secondary	Functionality and mobility - 3	handgrip strength in kilogramms	up to 12 months
Secondary	Functionality and mobility - 4	pedometer activPAL3 micro	up to 12 months
Secondary	Functionality and mobility - 5	Short physical performance battery (SPPB) in scale	up to 12 months
Secondary	Nutritional status	measured bei Mini Nutritional Assessment (MNA)	up to 12 months
Secondary	Health-related quality of life	Measured by Short-Form-Health Survey (SF-12) questionnaire in scale	up to 12 months
Secondary	Depression	Measured by Geriatric Depression Scale (GDS) in scale	up to 12 months
Secondary	Cognitive Status - 1	Measured by Mini-Mental State Examination (MMSE) in scale	up to 12 months
Secondary	Cognitive Status - 2	Trail Making Test A&B in seconds	up to 12 months
Secondary	Burden of informal caregivers - 1	Measured by Zarith-questionnaires in scale	up to 12 months
Secondary	Burden of informal caregivers - 2	Perceived Stress Questionnaire (PSQ)-questionnaires in scale	up to 12 months
Secondary	Transfers into nursing homes	Comparison between intervention and control group. Data made available by cooperating partner Allgemeine Ortskrankenkasse (AOK) sickness fund in percent	Up to 12 months
Secondary	Care situation, care supply and quality of care at home	Measured by Neues BegutAchtungsinstrument (NBA, Buscher, Wingenfeld & Schaeffer, 2011) as scale	up to 12 months