Supporting elderly people with cognitive impairment during and after hospital stays with intersectoral care management: study protocol for a randomized controlled trial

Abstract

Background: The sectorization of health-care systems leads to inefficient treatment, especially for elderly people with cognitive impairment. The transition from hospital care to primary care is insufficiently coordinated, and communication between health-care providers is often lacking. Consequences include a further deterioration of health, higher rates of hospital readmissions, and institutionalization. Models of collaborative care have shown their efficacy in primary care by improving patient-related outcomes. The main goal of this trial is to compare the effectiveness of a collaborative care model with usual care for people with cognitive impairment who have been admitted to a hospital for treatment due to a somatic illness. The aim of the intervention is to improve the continuity of treatment and care across the transition between the in-hospital and adjoining primary care sectors. Methods/design: The trial is a longitudinal multisite randomized controlled trial with two arms (care as usual and intersectoral care management). Inclusion criteria at the time of hospital admission due to a somatic illness are age 70+ years, cognitive impairment (Mini Mental State Examination, MMSE ≤26), living at home, and written informed consent. Each participant will have a baseline assessment at the hospital and two follow-up assessments at home (3 and 12 months after discharge). The estimated sample size is n = 398 people with cognitive inmpairement plus their respective informal caregivers (where available). In the intersectoral care management group, specialized care managers will develop, implement, and monitor individualized treatment and care based on comprehensive assessments of the unmet needs of the patients and their informal caregivers. These assessments will occur at the hospital and in participants' homes. Primary outcomes are (1) activities of daily living, (2) readmission to the hospital, and (3) institutionalization. Secondary outcomes include (a) frailty, (b) delirium, (c) quality of life, (d) cognitive status, (e) behavioral and psychological symptoms of dementia, (f) utilization of services, and (g) informal caregiver burden.

The situation of elderly with cognitive impairment living at home during lockdown in the Corona-pandemic in Germany

“…This analysis is based on data from a telephone-based questionnaire and semi-structured interview assessment in a convenience sample of n=141 people with cognitive impairment in the primary care setting in Mecklenburg-Western Pomerania and North-Rhine-Westphalia, respectively. Participants were recruited from currently running interventional trials intersec-CM (Supporting elderly people with cognitive impairment during and after hospital stays with intersectoral care management) [30] and the DCM:IMPact study (Dementia Care Management: Implementation into different Care Settings), an implementation study of the dementia care management of the DelpHi-MV trial [31][32][33]. The assessments were conducted during the time of the lockdown during study contacts between 22 nd of March and 5 th of June 2020, before restrictions were lifted.…”

The Situation of Elderly With Cognitive Impairment Living at Home During Lockdown in the Corona-pandemic in Germany

“…This analysis is based on data of a telephone-based questionnaire and semi-structured interview assessment in a convenience sample of n = 141 people with cognitive impairment in the primary care setting in Mecklenburg-Western Pomerania and North-Rhine-Westphalia. Participants were recruited from currently running interventional trials intersec-CM (Supporting elderly people with cognitive impairment during and after hospital stays with intersectoral care management) [30] and the DCM:IMPact study (Dementia Care Management: Implementation into different Care Settings), an implementation study of the dementia care management of the DelpHi-MV trial [31][32][33]. Ethical approval has been obtained from the ethics committee of Greifswald Medical School (registry number: BB 159/17) and the ethics committee of the Chamber of Physicians of Westfalen-Lippe (registry number: 2017-688-b-S).…”

Intersectoral care management for older people with cognitive impairment during and after hospital stays [intersec-CM]: study protocol for a process evaluation within a randomised controlled trial

“…The DelpHi-Care Management comprises a large number of different modules to optimise the care of people with dementia and their caregivers in the ambulatory setting. The DelpHi intervention was refined to a discharge management and is presently evaluated in the randomised controlled trial (RCT) intersec-CM [ 7 ]. At two study centres in Bielefeld and Greifswald, Germany, specially trained study nurses monitor the transition of the PCI from an acute care hospital back to their homes.…”

“…In the intervention group, the nurses will conduct the discharge management. The intersec-CM intervention consists of [ 5 ]: A comprehensive assessment of the health and social status of each patient at the time of admission to the acute care hospital A comprehensive needs assessment at the time of admission to the hospital An assessment of caregiver health and burden Provision of a systematic, written feedback to the treating hospital staff as well as the receiving physicians and respectively the patients and their caregivers with specific recommendations for treatment and care after discharge (hospital information letter) …”

“…In this intersectoral care management, the study nurses are responsible for the assessment as well as the delivery of the individualised intervention. They develop, implement and monitor treatment and care, based on the assessments of patients’ and caregivers’ unmet needs [ 5 ]. This will be realised in close cooperation with the treating hospital, the PCI’s general practitioner (GP) and other ambulatory healthcare providers including home care services, occupational therapy, physiotherapy and speech therapy [ 5 ].…”