Transitional care bridge

Patients of 65 years and above are at high risk for adverse outcomes after
acute hospital admission. A previous multicenter study (DEFENCE-II study,
demonstrated that 30 % of the patients showed a decline in activities of daily
living (ADL) functioning three months after hospital admission, compared to
premorbid ADL functioning and the mortality rate three months after hospital
admission is 20 %. Most diseases and geriatric conditions that contribute to
this poor outcomes could be subject for pro-active intervention, at the time of
hospital admission, during hospitalization, but also after hospitalization. The
hypothesis of this study is, that casefinding of vulnerable older patients at
high risk for a decline in ADL functioning and other adverse outcomes at
hospital admission, followed by a integrated care plan and follow up
(transitional care) of patients by a registered community nurse will decrease
functional decline after hospital admission, but will also decrease other
adverse outcomes, such as institutionalization, rehospitalisation and mortality
rates

The main objective is to study the effect of a pro-active, multi-component,
nurse-led transitional care program until six months after hospital admission
on ADL functioning.
Secondary objectives are:
To assess the effects of a pro-active, multi-component, nurse-led transitional
care program on mortality
To determine the feasibility of a pro-active, multi-component, nurse-led
transitional care program in primary care .

A multicenter, single-blinded, randomized clinical trial at the level of the
patient comparing a pro-active, multi-component, nurse-led transitional care
program to usual care after discharge

All patients receive integrated geriatric care during hospital admission,
consisting of casefinding for geriatric conditions, followed by an integrated
care plan and interventions during hospitalization. The intervention group will
receive a pro-active, multi-component, nurse-led transitional care program
consisting of a proactive handover moment one day before discharge of the older
patient, followed by a continuation of the integrated care plan in primary
care.

the participation in the study consists of a diagnostic assessment. The content
is of this diagnostic assessment on the presence of geriatric conditions is
resumed in appendix 2 and consist of several questionnaires. The assessment
will take 30 minutes in the first 48 hours of hospital admission and results in
an integrated care plan, which is discussed with the patient and his primary
care giver. Interventions will be started up, if necessary and can for example
consist of consulting the physiotherapist for physiotherapy and mobilization or
advice to nurses on prevention of delirium. Patients in the intervention group
will be visited by the registered community nurse one day before discharge and
furthermore one day after hospital discharge, two, six, twelve and twenty-four
weeks after discharge. During this home visits the care plan is evaluated and
the nurse can be contacted in case of any problems. The community care nurse
works in close collaboration with the GP of the patient.
Patients with cognitive impairment can also participate in this study. Informed
consent is then signed by the primary care giver.