AdvantAGE: Implementation and Evaluation of an Interprofessional Transitional Care Model for Frail Older Adults at the University Department of Geriatric Medicine FELIX PLATTER

What this Trial Is About

Researchers are evaluating a new transitional care model designed to help frail older adults after they leave the hospital. This study focuses on whether this model can reduce the number of patients who need to be readmitted within 90 days and how effectively the care model can be implemented. The trial is conducted at the University Department of Geriatric Medicine FELIX Platter in Basel, Switzerland, and involves older adults who are at high risk of health deterioration due to frailty. The care model includes five main components provided by a multiprofessional team: ongoing support for patients and caregivers, coordination with primary care providers, home visits, medication and self-management education, and proactive advanced care planning. Participants receive specialized support including home visits for up to 90 days following their hospital discharge. During the study, advanced practice nurses will follow participants and their caregivers for up to 90 days after discharge to assist in managing health conditions, coordinating care, and supporting medication and self-care. Researchers will measure outcomes such as the rate of rehospitalization within 90 days, emergency room visits, patients' quality of life, and satisfaction with care. The study carefully monitors participants throughout this period to assess the impact of the care model.

AdvantAGE: Implementation and Evaluation of an Interprofessional Tranistional Care Model for Frail Older Adults