Table 1 Components of ordinary care and Continuum of care
Intervention components | Ordinary care/control group | Continuum of care for frail older people |
|---|---|---|
Frailty screening and geriatric assessment at emergency department (ED) by nurse with geriatric competence | No | Yes, need of rehabilitation, nursing, geriatric and social care |
Case manager (CM) in the municipality with multi-professional team for care and rehabilitation | No | Yes |
Hospital care if needed and rehabilitation at hospital if needed | Yes | Yes |
Track 1. In need of hospital care: information transfer to ward and case manager in the municipality. CM responsible for contacting the ward and the patient in order to prepare the municipality in good time before being discharged | No | Yes |
Track 2. Not in need of hospital care: information transfer to case manager in the municipality | ||
Care planning | Yes, at hospital before discharge if assessed as having new or changed needs of home care by a team from the municipality consisting of different professionals (nurse, occupational therapist, physiotherapist or social worker) responsible for all care planning at the hospital Not for persons with no need of hospital care. | Yes, at home for both tracks within a couple of days of discharge, based on ED frailty screening and a comprehensive geriatric assessment by CM and team |
Rehabilitation in the municipality if assessed as needed at care planning | Yes | Yes |
Follow-ups other than research | Yes, after rehabilitation | Yes, by CM within a week after care planning and then at least every month for a year |