CompletedNot Applicable

Efficacy of Integrated Care to Reduce Hospitalization and Nursing Home Placement in Community Dwelling Frail Elderly

Switzerland301 participantsStarted 2009-07

Plain-language summary

Introduction: Care of frail and dependent elders with multiple chronic conditions is a major challenge for health care systems. The objective of this study is to evaluate the effect of coordinating the existing structures in the private and public sector for the care of frail and dependent persons over age 60, and susceptible of presenting complex bio-psycho-social issues. This approach is aimed at improving the coordination, continuity, quality and efficacy of care in this population, which presents a high risk of hospitalization, emergency room visits, institutionalization and mortality. Methods: Three-year cluster randomised controlled trial. A control group receiving usual care (follow up by primary care physician and home nursing service) will be compared to an intervention group that will be provided, in addition, in-home multidimensional geriatric assessment with access to a 24h/7 day a week call service, and coordinated long-term follow-up. Survival analyses will be conducted to compare the outcomes between groups. Primary outcome: \- Hospitalizations: rates of first hospitalization, number, cause and length of stay. Secondary outcomes: * Emergency room visits: rates of first visit, number and cause * Institutionalization: number of patients * Mortality: rate and number of deaths and place of death (home versus hospital)

Who can participate

Age range

60 Years

Sex

ALL

See this in plain English?

AI-rewrites the medical criteria so a patient or caregiver can understand them. Always confirm with the trial site.

Inclusion Criteria: * Patients followed by the home nursing service and primary care physician * Over 60 years of age * Able to give consent (patient or caregiver) * Able to speak French * Meeting frailty criteria as determined by one of the following alarms detected by the RAI-HC: * Alarm 8: cognition * Alarm 12: social role and function * Alarm 15: falls * Alarm 22: frailty of the informal care giver system. Exclusion Criteria: * Age under 60 years * Unable (patient or caregiver) to give informed consent * Unable to communicate adequately in French * Patients' not receiving nursing visits (only receiving practical aid or services from occupational therapists).

Questions worth asking your doctor

Bring these to your next appointment. They're a starting point for a shared conversation — not a sign you qualify or a recommendation to enrol.

1Based on my diagnosis and history, is this trial worth exploring for me — or is there a standard treatment we should try first?
2What does this trial's phase tell us about how much is already known about its safety and benefit?
3What would taking part actually involve for me — visits, tests, time, and travel?
4What are the known and possible risks or side effects I should weigh, and how would they be monitored?
5If this trial isn't the right fit, what other options or trials would you suggest I look into?

Generated to help you prepare — always confirm anything about your own eligibility and care with the study team and your doctor.

Questions for the trial coordinator

The trial coordinator is the person who runs the study day to day. These cover the practical side — logistics, costs, and what taking part would actually mean for your life. The study team confirms whether you meet the criteria; these are questions to ask, not a sign you qualify.

1What does taking part actually involve week to week — how many visits, where, and how long does each one take?
2What costs are covered by the study, and what might I have to pay for myself, including travel, parking, or time off work?
3What happens during screening, and what happens if the study team confirms I don't meet the criteria after those tests?
4Who pays for the scans, blood work, and other tests the trial requires — the study, my insurance, or me?
5How will being in the trial affect my regular care, and will my own doctor stay informed and involved?
6Can I leave the trial at any point if I change my mind, and what would happen to my care if I do?

A starting point for the conversation — always confirm anything about your own eligibility, costs, and care with the study team and your doctor.

What they're measuring

Hospitalizations: rates of first hospitalization, number and reason

Timeframe: Three years

Trial details

NCT IDNCT02084108

SponsorUniversity Hospital, Geneva

Sponsor typeOTHER

Study typeINTERVENTIONAL

Primary completion2012-12

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