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OpenTrials
Completed

NCT Number: NCT02094040

Municipality-based Post-discharge Follow-up Visits

The purpose of this study is to determine whether discharge follow-up visit by primary physician and community-based nurse affects the risk of early re-hospitalisation among high risk older people discharged from a medical ward.

Completed

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Key information

Conditions

Frailty Pathologic Processes Pathological Conditions, Signs and Symptoms Primary Care Readmission Transition

Age range

65 year and older

Sex eligibility

All sexes

Study type

Interventional

Phase

Not applicable

Primary location

Medicinsk Afdeling, Holbæk Sygehus

Holbæk, 4300, Denmark

Who can participate

Healthy volunteers accepted: No

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

Inclusion criteria

  • Patient geography (The participant live in; Holbæk Kommune, Odsherred Kommune or Kalundborg Kommune.)
  • Discharged from medical ward Holbæk Sygehus.
  • Frailty (Rated by following criterion: dementia or a minimum of two of the following conditions; two or more hospitalisations within 12 month prior to follow up, los of physical function, treatment of two or more concurrent medical and/or surgical conditions, psychiatric disease, multi-pharmacy of more than 6 prescription medication, suspicious of congenital disturbances, substance abuse problem, disadvantaged social network, need for increasing home care following index hospitalization.)

Exclusion criteria

  • Not discharged to home (If the patient are not discharged to home.)
  • No written consent (If the patient does not wish to participate / written consent are not signed.)

Treatment and study plan

Receive municipality-based follow-up visit

Behavioral

Systematic electronic referral from hospital to municipality of high risk people at discharge from a medical ward. Contact from municipality service to primary physician and citizen, to arrange first home visit within 7 days with focus on: medication, rehabilitation plan and health care appointments, functional level and need for further health care initiatives. The visit is concluded by planning of further visits (up till tree) and division of responsibilities between primary physician and the municipality service.

Other names: Intervention group

Primary outcomes

  1. Re-admission

    Time frame: Within 30 days from discharge

    The primary outcome is re-hospitalisation rate within 30 days from discharge. Data is obtained from the official register of danish patients (Landspatientregistret).

Secondary outcomes

  1. Long-term hospitalization rate

    Time frame: Within 180 days from discharge

    Secondary outcome concerns hospitalization rate measured at 30 and 180 days post discharge. Data is obtained from the official register of Danish patients (Landspatientregistret).

Other outcomes

  1. Long-term death rate

    Time frame: Within 180 days from discharge

    Other pre-specified outcome concerns death rate measured at 30 and 180 days post discharge. Data is obtained from the official register of Danish patients (Landspatientregistret).

  2. Long-term use of primary health care services

    Time frame: Within 180 days from discharge

    Other pre-specified outcome concerns the use of primary health care services measured at 30 and 180 days post discharge. Data is obtained from the official register of primary health care in Denmark (Sygesikringsregistret) and registration from 3 Danish municipalities.

  3. Long-term use of secondary health care services

    Time frame: Within 180 days from discharge

    Other pre-specified outcome concerns the use of secondary health care services measured at 30 and 180 days post discharge. Data is obtained from the official register of Danish patients (Landspatientregistret).

Sponsors and collaborators

Lead sponsor

Holbaek Sygehus

Other

Collaborators

  • Danish Institute for Public Health
  • Region Sjælland

Registry information

Official study title

Effect of Municipality-based Post-discharge Follow-up Visit Including the Primary Physician on Early Re-hospitalization in High Risk People of 65+ Years. A Randomised Controlled Trial.

Important dates

Study start
2012
Primary completion
2013
Study completion
2013
First posted
Mar 21, 2014
Registry last updated
Mar 21, 2014

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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