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Integrated Care Pathways in a Community Setting

This study has been completed.
Sponsor:
ClinicalTrials.gov Identifier:
NCT01107119
First Posted: April 20, 2010
Last Update Posted: April 20, 2017
The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details.
Collaborators:
The Research Council of Norway
St. Olavs Hospital
Nordmøre and Romsdal Hospital Trust
City of Trondheim
Local authorities of Orkdal
Local authorities of Surnadal
Local authorities of Sunndal
Local authorities of Fræna
Information provided by (Responsible Party):
Norwegian University of Science and Technology
  Purpose

The ambition of this study is to raise the quality of care for old and chronically ill patients by establishing a sustainable, systematic prevention and integrated care model for users of home care services.

In this cluster randomized study the intervention will be carried through in five municipalities and three general hospitals. The home care units in every municipality will be randomized to either intervention og control units.


Condition Intervention
Chronic Illness Other: integrated care pathway Other: usual care

Study Type: Interventional
Study Design: Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)
Primary Purpose: Health Services Research
Official Title: Enabling Elderly Patients to Manage Their Own Lives - A Systematic Management Program for Home Care Services.

Resource links provided by NLM:


Further study details as provided by Norwegian University of Science and Technology:

Primary Outcome Measures:
  • activities of daily living (ADL) [ Time Frame: 6 and 12 months ]
    Individbasert pleie- og omsorgsstatistikk (IPLOS) scale, and Nottingham Extended ADL Scale

  • Institutional health care at primary and secondary level [ Time Frame: 1 year ]
    Readmission (30 days)and inpatient hospital stays, number and length of stay (EPJ hospitals) Number and length of stay in municipal nursing homes (EPJ municipals) Days before permanent stay in municipal nursing homes


Secondary Outcome Measures:
  • Achieve better collaboration within primary care and between primary- and secondary health care providers [ Time Frame: 1 year ]
    Extract information on communication from EPJ municipal care and EPJ General practitioners


Enrollment: 304
Study Start Date: October 2009
Study Completion Date: October 2012
Primary Completion Date: March 2012 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Experimental: Integrated care pathway

program for

  1. communication and information flow aimed at collaboration between hospitals, general practitioners and home care services
  2. systematic patient follow-up in home care services by using checklists
Other: integrated care pathway
communication and follow-up program for integrated care
Active Comparator: usual care
usual care
Other: usual care

Detailed Description:

The primary objective of this study is to develop a functional and integrated care model between primary and secondary health care that will meet the needs both in the city and in smaller rural areas.

The secondary objective of this study is to reduce the need of care at primary and secondary level through a a systematic and integrated follow-up by home care nurses and general practitioners to:

  • Enable these patients to manage their health needs more efficiently and independently
  • Achieve better collaboration within primary care
  • Achieve better collaboration between primary- and secondary health care professionals
  • Achieve increased satisfaction and confidence with the health care services by the users and their relatives both for included patients and other patients receiving home care services.
  • Promote health and prevent unnecessary decline in health
  • Strengthen the patients' ability to manage their daily activities.
  Eligibility

Information from the National Library of Medicine

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Ages Eligible for Study:   70 Years and older   (Senior)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Person 70 years or above being discharged from the general hospital
  • Will receive home care services within four weeks after being discharges from the hospital.

Exclusion Criteria:

  • Do not agree or are not able to agree to participate
  • Is already involved in other research studies affecting the home care services.
  Contacts and Locations
Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT01107119


Locations
Norway
Fræna Municpality
Fræna, Norway
Molde hospital
Molde, Norway
Orkdal Municipality
Orkdal, Norway
Sunndal Municiplaity
Sunndal, Norway
Surnadal Municipality
Surnadal, Norway
St Olav's University hospital
Trondheim, Norway, 7006
Trondheim municiplaity
Trondheim, Norway
Sponsors and Collaborators
Norwegian University of Science and Technology
The Research Council of Norway
St. Olavs Hospital
Nordmøre and Romsdal Hospital Trust
City of Trondheim
Local authorities of Orkdal
Local authorities of Surnadal
Local authorities of Sunndal
Local authorities of Fræna
Investigators
Principal Investigator: Anders Grimsmo, md phd Norwegian University of Science and Technology
  More Information