Abstract
BackgroundThe 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/designThe 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.DiscussionIn the event of proving efficacy, this trial will deliver a proof of concept for implementation into routine care. The cost-effectiveness analyses as well as an independent process evaluation will increase the likelihood of meeting this goal. The trial will enable an in-depth analysis of mediating and moderating effects for different health outcomes at the interface between hospital care and primary care. By highlighting treatment and care, the study will provide insights into unmet needs at the time of hospital admission, and the opportunities and barriers to meeting those needs during the hospital stay and after discharge.Trial registrationClinicalTrials.gov, NCT03359408; December 2, 2017.
Highlights
The sectorization of health-care systems leads to inefficient treatment, especially for elderly people with cognitive impairment
The trial will enable an in-depth analysis of mediating and moderating effects for different health outcomes at the interface between hospital care and primary care
In a separate acceptance study, approximately 80% of the participating General physician or general practitioner (GP) indicated that care management as provided in the DelpHi-MV study should become a basic service in routine care [25]
Summary
The sectorization of health-care systems leads to inefficient treatment, especially for elderly people with cognitive impairment. 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. In Germany, the boundaries between sectors are often rigid, rendering transitions between sectors a threat to treatment continuity and care coordination, which often results in unfavorable outcomes for patients. After this problem was identified and described in detail by the Advisory Council on the Assessment of Developments in the Health Care System in 2012 [1], a number of different remedies were proposed. This study addresses the lack of integrated cross-sectoral approaches to the challenges caused by the sectorization of the German health-care system
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