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Table 1 Components of ordinary care and Continuum of care

From: One-year outcome of frailty indicators and activities of daily living following the randomised controlled trial; “Continuum of care for frail older people”

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