Improvement of transitional care from hospital to home for older patients, the TIGER study: protocol of a randomised controlled trial

Introduction In Germany, an efficient and feasible transition from hospital to home for older patients, ensuring continuous care across healthcare settings, has not yet been applied and evaluated. Based on the transitional care model (TCM), this study aims to reduce preventable readmissions of patie...

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Main Authors: Dorothee Volkert, Ellen Freiberger, Martina Rimmele, Jenny Wirth, Sabine Britting, Thomas Gehr, Margit Hermann, Dirk van den Heuvel, Andreas Kestler, Thomas Koch, Oliver Schoeffski, Klaus Wingenfeld, Susanne Wurm, Cornel Sieber
Format: Article
Language:English
Published: BMJ Publishing Group 2021-02-01
Series:BMJ Open
Online Access:https://bmjopen.bmj.com/content/11/2/e037999.full
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author Dorothee Volkert
Ellen Freiberger
Martina Rimmele
Jenny Wirth
Sabine Britting
Thomas Gehr
Margit Hermann
Dirk van den Heuvel
Andreas Kestler
Thomas Koch
Oliver Schoeffski
Klaus Wingenfeld
Susanne Wurm
Cornel Sieber
author_facet Dorothee Volkert
Ellen Freiberger
Martina Rimmele
Jenny Wirth
Sabine Britting
Thomas Gehr
Margit Hermann
Dirk van den Heuvel
Andreas Kestler
Thomas Koch
Oliver Schoeffski
Klaus Wingenfeld
Susanne Wurm
Cornel Sieber
author_sort Dorothee Volkert
collection DOAJ
description Introduction In Germany, an efficient and feasible transition from hospital to home for older patients, ensuring continuous care across healthcare settings, has not yet been applied and evaluated. Based on the transitional care model (TCM), this study aims to reduce preventable readmissions of patients ≥75 years of age with a transitional care intervention performed by geriatric-experienced care professionals. The study investigates whether the intervention ensures continuous care during transition and stabilises the care situation of patients at home.Methods and analyses Randomised controlled clinical trial, recruiting between 25 April 2018 and 31 December 2019 in one German hospital in the city of Regensburg. The intervention group is supported by care professionals in the transition process from hospital to home for up to 12 months. Based on TCM, the intervention includes an individual care plan according to a patient’s symptoms, risks, needs and values. The plan is advanced in the domestic situation via personal visits and telephone contacts. All necessary care actions regarding, for example, mobility, residence adjustments, or nutrition, are initiated to be executed by ambulant care services, and are monitored, evaluated and adapted if necessary. In supervising the care plan, the care professionals do not administer active care services themselves but coordinate them. Patients and their caregivers are actively engaged in the care planning and execution. In contrast, the control group receives only usual discharge planning in the hospital and usual ambulatory care.The primary outcome is the all-cause readmission rate assessed using health insurance data within a follow-up of up to 12 months after hospital discharge. Secondary outcomes include care quality, mobility, nutritional and wound situation, and health-related quality of life. They are assessed at baseline, after 1 month, 3 months, 6 months, and at the end of study visit. Additionally, the economic efficiency of the intervention will be evaluated.Ethics and dissemination Ethics approval for the trial was obtained from the Ethics Committee of the Friedrich-Alexander-Universität Erlangen-Nürnberg. Results will be published in peer-reviewed, open-access scientific journals and disseminated at national and international research conferences and through public presentations in the geriatric and healthcare community.Trial registration ClinicalTrials.gov identifier: NCT03513159.
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spelling doaj-art-48d5a9a40c8d42089364549b0b8b88852024-11-17T10:05:07ZengBMJ Publishing GroupBMJ Open2044-60552021-02-0111210.1136/bmjopen-2020-037999Improvement of transitional care from hospital to home for older patients, the TIGER study: protocol of a randomised controlled trialDorothee Volkert0Ellen Freiberger1Martina Rimmele2Jenny Wirth3Sabine Britting4Thomas Gehr5Margit Hermann6Dirk van den Heuvel7Andreas Kestler8Thomas Koch9Oliver Schoeffski10Klaus Wingenfeld11Susanne Wurm12Cornel Sieber13Institute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nürnberg, Bayern, GermanyInstitute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nuremberg, GermanyInstitute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nuremberg, GermanyInstitute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nuremberg, GermanyInstitute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nuremberg, GermanyInstitute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nuremberg, GermanyAOK Bavaria, Munich, GermanyFederal Association of Geriatrics, Berlin, GermanySt John of God Hospital, Regensburg, GermanyRegensburger Ärztenetz, Regensburg, Germany9 Chair of Health Management, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nuremberg, GermanyInstitute for Nursing Science at the University of Bielefeld, Bielefeld, GermanyInstitute for Community Medicine, Department of Social Medicine and Prevention, University of Greifswald Faculty of Medicine, Greifswald, GermanyInstitute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nuremberg, GermanyIntroduction In Germany, an efficient and feasible transition from hospital to home for older patients, ensuring continuous care across healthcare settings, has not yet been applied and evaluated. Based on the transitional care model (TCM), this study aims to reduce preventable readmissions of patients ≥75 years of age with a transitional care intervention performed by geriatric-experienced care professionals. The study investigates whether the intervention ensures continuous care during transition and stabilises the care situation of patients at home.Methods and analyses Randomised controlled clinical trial, recruiting between 25 April 2018 and 31 December 2019 in one German hospital in the city of Regensburg. The intervention group is supported by care professionals in the transition process from hospital to home for up to 12 months. Based on TCM, the intervention includes an individual care plan according to a patient’s symptoms, risks, needs and values. The plan is advanced in the domestic situation via personal visits and telephone contacts. All necessary care actions regarding, for example, mobility, residence adjustments, or nutrition, are initiated to be executed by ambulant care services, and are monitored, evaluated and adapted if necessary. In supervising the care plan, the care professionals do not administer active care services themselves but coordinate them. Patients and their caregivers are actively engaged in the care planning and execution. In contrast, the control group receives only usual discharge planning in the hospital and usual ambulatory care.The primary outcome is the all-cause readmission rate assessed using health insurance data within a follow-up of up to 12 months after hospital discharge. Secondary outcomes include care quality, mobility, nutritional and wound situation, and health-related quality of life. They are assessed at baseline, after 1 month, 3 months, 6 months, and at the end of study visit. Additionally, the economic efficiency of the intervention will be evaluated.Ethics and dissemination Ethics approval for the trial was obtained from the Ethics Committee of the Friedrich-Alexander-Universität Erlangen-Nürnberg. Results will be published in peer-reviewed, open-access scientific journals and disseminated at national and international research conferences and through public presentations in the geriatric and healthcare community.Trial registration ClinicalTrials.gov identifier: NCT03513159.https://bmjopen.bmj.com/content/11/2/e037999.full
spellingShingle Dorothee Volkert
Ellen Freiberger
Martina Rimmele
Jenny Wirth
Sabine Britting
Thomas Gehr
Margit Hermann
Dirk van den Heuvel
Andreas Kestler
Thomas Koch
Oliver Schoeffski
Klaus Wingenfeld
Susanne Wurm
Cornel Sieber
Improvement of transitional care from hospital to home for older patients, the TIGER study: protocol of a randomised controlled trial
BMJ Open
title Improvement of transitional care from hospital to home for older patients, the TIGER study: protocol of a randomised controlled trial
title_full Improvement of transitional care from hospital to home for older patients, the TIGER study: protocol of a randomised controlled trial
title_fullStr Improvement of transitional care from hospital to home for older patients, the TIGER study: protocol of a randomised controlled trial
title_full_unstemmed Improvement of transitional care from hospital to home for older patients, the TIGER study: protocol of a randomised controlled trial
title_short Improvement of transitional care from hospital to home for older patients, the TIGER study: protocol of a randomised controlled trial
title_sort improvement of transitional care from hospital to home for older patients the tiger study protocol of a randomised controlled trial
url https://bmjopen.bmj.com/content/11/2/e037999.full
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