Municipality-based Post-discharge Follow-up Visits

Holbaek Sygehus

Status

Completed

Conditions

Transition

Readmission

Frailty

Primary Care

Treatments

Behavioral: Receive municipality-based follow-up visit

Study type

Interventional

Funder types

Other

Identifiers

NCT02094040

3800H0.52-0059

Details and patient eligibility

About

The purpose of this study is to determine whether discharge follow-up visit by primary physician and community-based nurse affects the risk of early re-hospitalisation among high risk older people discharged from a medical ward.

Enrollment

531 patients

Sex

All

Ages

65+ years old

Volunteers

No Healthy Volunteers

Inclusion criteria

Patient geography (The participant live in; Holbæk Kommune, Odsherred Kommune or Kalundborg Kommune.)
Discharged from medical ward Holbæk Sygehus.
Frailty (Rated by following criterion: dementia or a minimum of two of the following conditions; two or more hospitalisations within 12 month prior to follow up, los of physical function, treatment of two or more concurrent medical and/or surgical conditions, psychiatric disease, multi-pharmacy of more than 6 prescription medication, suspicious of congenital disturbances, substance abuse problem, disadvantaged social network, need for increasing home care following index hospitalization.)

Exclusion criteria

Not discharged to home (If the patient are not discharged to home.)
No written consent (If the patient does not wish to participate / written consent are not signed.)