Abstract
BackgroundHospitalisations are a critical event in the care process. Insufficient communication and uncoordinated follow-up care often impede the recovery process of the patient resulting in a high number of rehospitalisations and increased health care costs. The overall aim of this study is the development, implementation and evaluation of a structured programme (VESPEERA) to improve the admission and discharge process.MethodsWe will conduct an open quasi-experimental multi-centre study with four intervention arms. A cohort selected from insurance claims data will serve as a control group reflecting usual care. The intervention will be implemented in 25 hospital departments and 115 general practices in 9 districts in Baden-Wurttemberg. Eligibility criteria for patients are: age > 18 years, hospital admission or hospitalisation, insurance at the sickness fund “AOK Baden-Wurttemberg”, enrolment in general practice-centred care contract. Each study arm will receive different intervention components based on the point of study enrolment and the patient’s medical need. The interventions comprise a) a structured assessment in the general practice prior to admission resulting in an admission letter b) a discharge conversation by phone between hospital and general practice, c) a structured assessment and care plan post-discharge and d) telephone monitoring for patients with a high risk of rehospitalisation. The assessments are supported by a software tool (“CareCockpit”), originally developed for structured case management programmes. The primary outcome (rehospitalisation due to the same indication within 90 days) and a range of secondary outcomes (rehospitalisation due to the same indication within 30 days; hospitalisations due to ambulatory care-sensitive conditions; delayed prescription of medication and medical products/ devices and referral to other health practitioner/s after discharge; utilisation of emergency or rescue services within 3 months; average care cost per year and patient participating in the VESPEERA programme) and quality indicators will be determined based on insurance claims data and CareCockpit data. Additionally, a patient survey on satisfaction with cross-sectoral care and health related quality of life will be conducted.DiscussionBased on the results, area-wide implementation in usual care is well sought. This study will contribute to an improvement of cross-sectoral care during the admission and discharge process.Trial registrationDRKS00014294 on DRKS / Universal Trial Number (UTN): U1111–1210-9657, Date of registration 12/06/2018.
Highlights
Hospitalisations are a critical event in the care process
This study will contribute to an improvement of cross-sectoral care during the admission and discharge process
Patients are often discharged at short notice, resulting in a lack of coordination of follow-up care and sufficient communication between care providers of the inpatient and outpatient sector and to the patient [1,2,3]
Summary
Hospitalisations are a critical event in the care process. Insufficient communication and uncoordinated follow-up care often impede the recovery process of the patient resulting in a high number of rehospitalisations and increased health care costs. Patients are often discharged at short notice, resulting in a lack of coordination of follow-up care and sufficient communication between care providers of the inpatient and outpatient sector and to the patient [1,2,3] This can be due to different organisational procedures and different views on the patient and responsibilities with regard to the care process between hospitals and general practices [4] as well as between interprofessional teams [5]. The resulting interruptions in the continuity of care can affect the recovery process and healthcare related patient satisfaction At worst, they can lead to avoidable rehospitalisations and adverse events [1, 4], which are relevant clinical outcomes and associated with increased care costs. A project on harmonisation of admission and discharge medication showed the need for improvement of information brokerage concerning pre- and post- hospital medication as well as structured medication counseling after discharge [3]
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