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

Launched by THEKLA BRUNKERT · Jan 3, 2024

Keywords

ClinConnect Summary

The AdvantAGE trial is studying a new way to help frail older adults transition from the hospital back to their homes. The focus is on whether this new care model can reduce the number of patients who need to return to the hospital within 90 days after discharge. The study will involve advanced practice nurses who will support participants and their caregivers for up to three months. They will help with coordinating care, managing medications, and understanding how to take care of health conditions. There will also be discussions about planning for future healthcare decisions.

To be eligible for this trial, participants must be at least 65 years old, currently in a hospital or rehabilitation unit, and live in the Basel-Stadt area. They should also be able to speak and understand German. It’s important that the patients are identified by a healthcare provider as being at high risk for health decline due to frailty. Those who live alone without support or have complex chronic diseases may also qualify. However, those residing in nursing homes or with severe cognitive impairments are not eligible. Participants can expect personalized support during their recovery, which aims to improve their overall health and wellbeing after leaving the hospital.

Gender

ALL

Eligibility criteria

• Inclusion Criteria:
• • Currently admitted to the acute or rehabilitation ward of University Department of Geriatric Medicine
• • Reside in Basel-Stadt
• • Possess the ability to speak and comprehend the German language
• • Scheduled to be discharged to their home
• • 65 years or older
• • Identified by a clinician as having a high risk of deterioration due to frailty
• Additionally, participants must meet at least one of the following criteria:
• • diagnosed with a complex chronic disease requiring support in self-management and disease management, or
• • facing socially challenging situations such as living alone without a supportive network or lacking a GP, or
• • admitted for an acute illness with a brief hospital stay (e.g., infection, cardiac decompensation) and need support in self- and disease management, and continuity of the therapy plan, including close monitoring.
• Exclusion Criteria:
• • residing in a nursing home or being newly admitted to one
• • lacking informal caregivers and exhibiting severe cognitive impairment (MMS ≤23)
• • scoring \<50 on the motoric domain of the Functional Independence Measure (FIM)
• • having a psychiatric disorder that significantly impacts their ability to manage daily life at time of the discharge