Bridging the Gap: Creating a Continuum of Care Through Active Follow-up by a Case Manager After Discharge - a Controlled Study

What this Trial Is About

Coordination and integration between different care settings is crucial for providing quality care to frail older adults. This research aims to evaluate the effects of active follow-up by a case manager (CM) in primary care after discharge from an acute geriatric hospital ward. The study explores whether this follow-up can help maintain or improve independence in daily activities, self-rated health, life satisfaction, satisfaction with health care, and reduce health care use and costs. It also assesses the feasibility of the intervention from the perspectives of caregivers and older patients. The intervention involves a CM, typically a nurse, who actively follows up after discharge by ensuring that discharge and care plans are carried out and addressing any new or unmet needs. If additional care or rehabilitation is needed, the CM coordinates with relevant health providers such as general practitioners or home help services. Participants are divided into an intervention group receiving this active follow-up and a control group receiving usual care without active follow-up. The study is controlled but non-randomized. Participants are followed by the research team for one year to monitor their dependency in activities of daily living, self-rated health, life satisfaction, satisfaction with care, and health care consumption. Data is collected at baseline and during the 12-month follow-up. The study also includes a process evaluation to understand how well the intervention and study design work for both caregivers and participants. The total participation time for each individual is one year from discharge.

Bridging the Gap: Creating a Continuum of Care