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Integrated Care Pathways in a Community Setting

This study is ongoing, but not recruiting participants.
Sponsor:
Collaborators:
The Research Council of Norway
St. Olavs Hospital
Nordmøre and Romsdal Hospital Trust
City of Trondheim
Local authorities of Orkdal
Local authorities of Surnadal
Local authorities of Sunndal
Local authorities of Fræna
Information provided by (Responsible Party):
Norwegian University of Science and Technology
ClinicalTrials.gov Identifier:
NCT01107119
First received: April 18, 2010
Last updated: January 31, 2013
Last verified: January 2013
History of Changes
  Purpose

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.


Condition Intervention
Chronic Illness
 Other: integrated care pathway
Other: usual care

Study Type: Interventional
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.

Resource links provided by NLM:

U.S. FDA Resources

Further study details as provided by Norwegian University of Science and Technology:

Primary Outcome Measures:
  • 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


Secondary Outcome Measures:
  • 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


Enrollment: 308
Study Start Date: October 2009
Estimated Study Completion Date: December 2013
Primary Completion Date: March 2012 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Experimental: Integrated care pathway

program for

  1. communication and information flow aimed at collaboration between hospitals, general practitioners and home care services
  2. systematic patient follow-up in home care services by using checklists
 Other: integrated care pathway
communication and follow-up program for integrated care
Active Comparator: usual care
usual care
 Other: usual care

Detailed Description:

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.
  Eligibility

Ages Eligible for Study:   70 Years and older
Genders Eligible for Study:   Both
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Person 70 years or above being discharged from the general hospital
  • Will receive home care services within four weeks after being discharges from the hospital.

Exclusion Criteria:

  • Do not agree or are not able to agree to participate
  • Is already involved in other research studies affecting the home care services.
  Contacts and Locations
Please refer to this study by its ClinicalTrials.gov identifier: NCT01107119

Locations
Norway
Fræna Municpality
Fræna, Norway
Molde hospital
Molde, Norway
Orkdal Municipality
Orkdal, Norway
Sunndal Municiplaity
Sunndal, Norway
Surnadal Municipality
Surnadal, Norway
Trondheim municiplaity
Trondheim, Norway
St Olav's University hospital
Trondheim, Norway, 7006
Sponsors and Collaborators
Norwegian University of Science and Technology
The Research Council of Norway
St. Olavs Hospital
Nordmøre and Romsdal Hospital Trust
City of Trondheim
Local authorities of Orkdal
Local authorities of Surnadal
Local authorities of Sunndal
Local authorities of Fræna
Investigators
Principal Investigator: Tove Røsstad, PhD student Norwegian University of Science and Technology
  More Information

No publications provided

Responsible Party: Norwegian University of Science and Technology
ClinicalTrials.gov Identifier: NCT01107119     History of Changes
Other Study ID Numbers: 21528
Study First Received: April 18, 2010
Last Updated: January 31, 2013
Health Authority: Norway:National Committee for Medical and Health Research Ethics

Keywords provided by Norwegian University of Science and Technology:
Frail elderly
Chronic illness
Integrated care model
Clinical pathways
Home care services

Additional relevant MeSH terms:
Chronic Disease
Disease Attributes
Pathologic Processes

ClinicalTrials.gov processed this record on May 19, 2013