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Completed

NCT Number: NCT03180606

Enhanced Primary Care for Elderly

The present health care situation for the elderly in many countries is insufficient and not designed according to the health care needs of the aged population. In a pragmatic multicenter primary care setting (n= 1600), the investigators use an evidence based prediction model to find elderly (75+) with high risk for complex medical care or hospitalization and apply a differentiated and directed medical and social care to this risk group, in comparison to usual care. The intervention will include all the latest evidence based tools in the care of elderly (multi-professional team, social support, medical care home-visits, telephone support, general practitioner visits, etc). The project has high potential impact on the development of future care of elderly.

In addition to the intervention study, several academic sub-studies focusing on patient's perspective, professional roles, equality, implementation and governance management of health care will be performed.

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Key information

Conditions

Frail Elderly Syndrome

Age range

75 year–110 year

Sex eligibility

All sexes

Study type

Observational

Primary location

Primary Care of Östergötland, Linköping, Östergötland County, Sweden

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About this study

The current project is a multidisciplinary research project covering several aspects of a shift in elderly care, with outcome measures not only related to primary medical or functional measures. The analyses will widen the view to overall societal costs and effects of changes in key institutions of social security as well as to hidden mechanisms in the governance system of care and health care of elderly.

The primary aim of the present study is to investigate the extent to which a differentiated (personalized) and targeted primary care intervention provided to a statistically predicted risk population of elderly, results in care that is more effective and of higher quality than that of a control group receiving standard care. In a pragmatic multicenter primary care setting (n= 1600), an evidence based prediction model to find elderly (75+) with high risk for complex medical care or hospitalization is used followed by a differentiated and directed medical and social care to this risk group, in comparison to usual care. The intervention will include all the latest evidence based tools in the care of elderly (multi-professional team, social support, medical care home-visits, telephone support, general practitioner visits, etc).

The investigators also aim to study the care model in a broader sense; experiences of the elderly, their social networks and diversity. Finally, the project will also investigate how the health care system, from specific health care professionals (primary care nurses, doctors, para-medical staff) to management levels and politicians influence the implementation of the present and future care models. One specific subproject focuses on the mechanisms behind the inability of steak holders/politicians and top administrative executives to find efficient governance principals for elderly care and health care, despite already available knowledge sources.

Who can participate

Only the study team can determine whether someone qualifies for participation.

Inclusion criteria

  • Age 75 years and older living in county of Östergötland

Exclusion criteria

  • No exclusion criteria

Treatment and study plan

Multi-disciplinary and personalized primary care

Other

Team-based primary care where nurse, GP, social-worker, physiotherapist, occupational therapist evaluate and give treatment

Primary outcomes

  1. Hospital care days

    Time frame: January 1st 2018 - December 31st 2019

    The number of days in hospital

Secondary outcomes

  1. Hospital care occasions

    Time frame: January 1st 2018 - December 31st 2019

    Number of occasions in hospital care

  2. Health related quality of life

    Time frame: January 1st 2018 - December 31st 2019

    Measured as EQ-5D scores

  3. Costs for health care

    Time frame: January 1st 2018 - December 31st 2019

    The total costs for health care measured in USD

  4. Mortality

    Time frame: January 1st 2018 - December 31st 2019

    Number of deaths during the study period

Sponsors and collaborators

Lead sponsor

Region Östergötland

Other

Registry information

Official study title

Enhanced Primary Care for Elderly: A Multicenter Pragmatic Clinical Trial Where Older People With Great Needs Are Predicted and Given Personalized Primary Care

Important dates

Study start
2017
Primary completion
2019
Study completion
2019
First posted
Jun 8, 2017
Registry last updated
Jun 5, 2020

OpenTrials presents study information sourced from ClinicalTrials.gov. The official registry record should be consulted for the latest information.

View the official ClinicalTrials.gov record (opens in a new tab)

This listing is for discovery and informational purposes only. It is not medical advice, does not guarantee that a study is recruiting, and does not determine eligibility. Contact the study team and a qualified healthcare professional when considering participation.

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