Integrated Care Pathways in a Community Setting
The ambition of this study is to raise the quality of care for old and chronically ill patients by establishing a sustainable, systematic prevention and integrated care model for users of home care services.
In this cluster randomized study the intervention will be carried through in five municipalities and three general hospitals. The home care units in every municipality will be randomized to either intervention og control units.
|Study Design:||Allocation: Randomized
Endpoint Classification: Efficacy Study
Intervention Model: Parallel Assignment
Masking: Open Label
Primary Purpose: Health Services Research
|Official Title:||Enabling Elderly Patients to Manage Their Own Lives - A Systematic Management Program for Home Care Services.|
- activities of daily living (ADL) [ Time Frame: 6 and 12 months ] [ Designated as safety issue: No ]Individbasert pleie- og omsorgsstatistikk (IPLOS) scale, and Nottingham Extended ADL Scale
- Institutional health care at primary and secondary level [ Time Frame: 1 year ] [ Designated as safety issue: No ]Readmission (30 days)and inpatient hospital stays, number and length of stay (EPJ hospitals) Number and length of stay in municipal nursing homes (EPJ municipals) Days before permanent stay in municipal nursing homes
- Achieve better collaboration within primary care and between primary- and secondary health care providers [ Time Frame: 1 year ] [ Designated as safety issue: No ]Extract information on communication from EPJ municipal care and EPJ General practitioners
|Study Start Date:||October 2009|
|Estimated Study Completion Date:||September 2014|
|Primary Completion Date:||March 2012 (Final data collection date for primary outcome measure)|
Experimental: Integrated care pathway
Other: integrated care pathway
communication and follow-up program for integrated care
Active Comparator: usual care
|Other: usual care|
The primary objective of this study is to develop a functional and integrated care model between primary and secondary health care that will meet the needs both in the city and in smaller rural areas.
The secondary objective of this study is to reduce the need of care at primary and secondary level through a a systematic and integrated follow-up by home care nurses and general practitioners to:
- Enable these patients to manage their health needs more efficiently and independently
- Achieve better collaboration within primary care
- Achieve better collaboration between primary- and secondary health care professionals
- Achieve increased satisfaction and confidence with the health care services by the users and their relatives both for included patients and other patients receiving home care services.
- Promote health and prevent unnecessary decline in health
- Strengthen the patients' ability to manage their daily activities.
|St Olav's University hospital|
|Trondheim, Norway, 7006|
|Principal Investigator:||Anders Grimsmo, md phd||Norwegian University of Science and Technology|