Bridging the gap: creating a continuum of care through active follow-up by a case manager after discharge – a controlled study

Research problem and specific questionsCoordination and integration between care settings is essential for the quality of care of frail older patients.

An active follow-up by a case manager (CM) after discharge form an acute geriatric hospital ward has the potential to bridge the gap between hospital, primary and municipality care for frail older people.

This study evaluates the effects of an active follow-up by a CM in primary care after discharge from a geriatric ward, with the following research questions:Can an active follow-up by CM for frail older people discharged from an acute geriatric ward, compared to those not receiving active follow up,Maintain/increase independence in activities of daily living, self-rated health and life satisfaction?Increase satisfaction with health care?Reduce health care consumption/be cost-effective?How feasible is the intervention and the study design from the perspective of the caregivers and the older person?Data and methodA clinical controlled study with a process evaluation.

Inclusion criteria are 75-years or older, frail and admitted to a geriatric ward.Societal relevance and utilisationToday’s highly specialized acute care is poorly adapted to the comprehensive needs of frail older people, and exposes them to avoidable risks such as loss of functional capacities causing unnecessary care needs and decreased wellbeing.

Active follow-up by a CM after discharge may be an important way to integrate the care for frail older people, after receiving in-hospital geriatric care.

This can improve the quality of care for this vulnerable group, and direct the right health care actions towards those in most need. Plan for project realisationIntervention: active follow-up after discharge by a CM (nurse) in primary care. CM will secure that discharge and care plans are executed and to address new needs.

If there are unmet needs, the CM will ensure that adequate actions are performed to meet the needs.Intervention group: participants discharged to a primary health care centre with a CM, who actively follows-up after discharge.Control group: participants discharged to a primary health care centre without CM, and thereby no active follow-up after discharge.The participants will be followed-up by the research team during one year, concerning dependence in activities of daily living, self-rated health, health care consumption and satisfaction with care.

The costs for the project is mainly for data collection and analyses.