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

Last updated: February 1, 2024
Sponsor: Thekla Brunkert
Overall Status: Active - Recruiting

Phase

N/A

Condition

N/A

Treatment

Transitional care model

Clinical Study ID

NCT06190288
02072
  • Ages > 65
  • All Genders

Study 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.

Eligibility Criteria

Inclusion

Inclusion Criteria:

  • Currently admitted to the acute or rehabilitation ward of University Department ofGeriatric 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 anddisease management, or
  • facing socially challenging situations such as living alone without a supportivenetwork or lacking a GP, or
  • admitted for an acute illness with a brief hospital stay (e.g., infection, cardiacdecompensation) and need support in self- and disease management, and continuity ofthe therapy plan, including close monitoring.

Exclusion

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 dailylife at time of the discharge

Study Design

Total Participants: 250
Treatment Group(s): 1
Primary Treatment: Transitional care model
Phase:
Study Start date:
January 08, 2024
Estimated Completion Date:
June 30, 2026

Connect with a study center

  • Universitäre Altersmedizin FELIX PLATTER

    Basel, 4055
    Switzerland

    Active - Recruiting

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