Continuum of Care for Frail Elderly People

• Health care consumption [ Time Frame: 1 year ] [ Designated as safety issue: No ]
• functional ability [ Time Frame: 1 year ] [ Designated as safety issue: No ]
  mobility, strength, balance, activities of daily living. Changes from baseline measured at 3 months, 6 months and 1 year.
• satisfaction with health and social care [ Time Frame: 1 year ] [ Designated as safety issue: No ]

• Life satisfaction [ Time Frame: 1 year ] [ Designated as safety issue: No ]
• Number of participant reporting suffering fatigue/tiredness [ Time Frame: 1 year ] [ Designated as safety issue: No ]
  Answering Yes to the question "Have you suffered any general fatigue/tiredness over the last three months"
• physical activity [ Time Frame: 1 year ] [ Designated as safety issue: No ]
• Number of participants with impaired cognition [ Time Frame: 1 year ] [ Designated as safety issue: No ]
  Scoring below 25 on Mini Mental State Examination
• visual impairment [ Time Frame: 1 year ] [ Designated as safety issue: No ]
• quality of life [ Time Frame: 1 year ] [ Designated as safety issue: No ]
• accessibility [ Time Frame: 1 year ] [ Designated as safety issue: No ]
• social support [ Time Frame: 1 year ] [ Designated as safety issue: No ]
• Number of participants reporting falls last thre months and fear of falling [ Time Frame: 1 year ] [ Designated as safety issue: Yes ]
  Number of falls during the last three months and Falls Efficacy Scale
• decisional autonomy [ Time Frame: 1 year ] [ Designated as safety issue: No ]
• The cumulative illness rating scale for geriatrics [ Time Frame: 1 year ] [ Designated as safety issue: No ]
  The total number of categories endorsed and number of categories at level 3 and/or 4 severity on The cumulative illness rating scale for geriatrics
• death [ Time Frame: 1 year ] [ Designated as safety issue: No ]
  Mortality rates from The Swedish national cause of death register

The present study "Continuum of care for frail elderly people" form part of the research programme "Support for frail elderly persons - from prevention to palliation" (www.vardalinstitutet.net) which comprises research into three interventions. The program comprises interventions addressing frail elderly people in different phases of the disablement process, from elderly people who are beginning to develop frailty to very frail elderly people receiving palliative care.

The intervention "Continuum of care for frail elderly people" addresses elderly people who are frail and that have a great risk of high health care consumption. The hypothesis is that an intervention program for frail elderly people can reduce the number of visits to the emergency department, increase the life satisfaction and maintain the functional ability. The intervention, including an early geriatric assessment at the emergency department, early family support, a case manager in the community with a multi-professional team and active follow-up by the case manager, contributes to early recognition of the elderly people's need of information, care and rehabilitation and of informal caregivers' need of information. It enhances the transfer of information and integrates the care between different caregivers and different care levels, thereby better recognize frail elderly people's needs. Specifically, this study is expected to show that the intervention has a positive effect on the frail elderly person's functional ability, life satisfaction, satisfaction with health and social care, and health care consumption.

• No Intervention: Conventional care, controlgroup
• Experimental: integrated health care chain
  integrated health care chain. Geriatric assessment at emergency department (ED), case manager with multiprofessional team in the community, support for informal caregivers
  Intervention: Other: integrated health care chain

• Hasson H, Blomberg S, Dunér A. Fidelity and moderating factors in complex interventions: a case study of a continuum of care program for frail elderly people in health and social care. Implement Sci. 2012 Mar 22;7:23.
• Wilhelmson K, Duner A, Eklund K, Gosman-Hedström G, Blomberg S, Hasson H, Gustafsson H, Landahl S, Dahlin-Ivanoff S. Design of a randomized controlled study of a multi-professional and multidimensional intervention targeting frail elderly people. BMC Geriatr. 2011 May 14;11(1):24.

Inclusion Criteria:

• 80 years and older or 65 to 79 years and having at least one chronic disease and being dependent in at least one activity of daily living

Exclusion Criteria:

• acute severely sick who immediately needs the assessment of a physician (within ten minutes)
• those with diagnosis of dementia (or severe cognitive impairment)
• patients in palliative care