A randomised clinical trial on comprehensive geriatric assessment and intensive follow up after hospital discharge: The transitional care bridge.

This multicenter, double-blind, randomized clinical trial compares a pro-active multi-component nurse-led transitional care program to usual care after discharge. Three hospitals in the Netherlands will participate in the study. All patients ≥ 65 years acutely admitted to the department of internal medicine, hospitalized for at least 48 hours and at risk for functional decline are invited to participate. All patients will receive integrated geriatric care during by a geriatric consultation team during hospital admission. Randomization, which will be stratified by study site and cognitive impairment, will be conducted during admission. The intervention group will receive the transitional care bridge program, consisting of a handover moment with a community care nurse (CN) during hospital admission and five home visits after discharge by the CN. The control group will receive ‘care as usual’ after discharge.
Main outcome is the level of ADL functioning six months after discharge compared to premorbid functioning measured with the Katz ADL index. Secondary outcomes include survival, cognitive functioning, quality of life, and health care utilization, satisfaction of the patient and primary care giver with the transitional care bridge program. All outcomes will be measured at three, six and twelve months after discharge. A total of 674 patients will be enrolled and are allocated to the intervention or control group.

Geriatric assessment at hospital admission followed by intensive home follow up by a community care nurse will reduce the rate of functional decline six months after admission in acutely hospitalized patients of 65 years and above.

All outcomes will be measured at three, six and twelve months after discharge.

The intervention group will receive the transitional care bridge program, consisting of a handover moment with a community care nurse (CN) during hospital admission and five home visits after discharge by the CN. The control group will receive ‘care as usual’ after discharge.