Continuum of Care for Frail Elderly People


The present study "Continuum of care for frail elderly people" form part of the research programme "Support for frail elderly persons – from prevention to palliation" ( which comprises research into three interventions. The program comprises interventions addressing frail elderly people in different phases of the disablement process, from elderly people who are beginning to develop frailty to very frail elderly people receiving palliative care.

The intervention "Continuum of care for frail elderly people" addresses elderly people who are frail and that have a great risk of high health care consumption. The hypothesis is that an intervention program for frail elderly people can reduce the number of visits to the emergency department, increase the life satisfaction and maintain the functional ability. The intervention, including an early geriatric assessment at the emergency department, early family support, a case manager in the community with a multi-professional team and active follow-up by the case manager, contributes to early recognition of the elderly people's need of information, care and rehabilitation and of informal caregivers' need of information. It enhances the transfer of information and integrates the care between different caregivers and different care levels, thereby better recognize frail elderly people's needs. Specifically, this study is expected to show that the intervention has a positive effect on the frail elderly person's functional ability, life satisfaction, satisfaction with health and social care, and health care consumption.

Full Title of Study: “Continuum of Care, From the Emergency Ward to Living at Home – Implementation and Evaluation of an Intervention for Frail Elderly People”

Study Type

  • Study Type: Interventional
  • Study Design
    • Allocation: Randomized
    • Intervention Model: Parallel Assignment
    • Primary Purpose: Supportive Care
    • Masking: None (Open Label)
  • Study Primary Completion Date: June 2010


  • Other: integrated health care chain
    • Geriatric assessment at ED, case manager with multiprofessional team in the community, support for informal caregivers

Arms, Groups and Cohorts

  • No Intervention: Conventional care, controlgroup
    • conventional care, control group
  • Experimental: integrated health care chain
    • integrated health care chain. Geriatric assessment at emergency department (ED), case manager with multiprofessional team in the community, support for informal caregivers

Clinical Trial Outcome Measures

Primary Measures

  • Health Care Consumption
    • Time Frame: 1 year
    • Number of hospital days and admission will be analysed
  • Dependence in Activities of Daily Living
    • Time Frame: 1 year
    • Changes in number of person dependent in one or more daily activity from baseline to follow-up.
  • Satisfaction With Health and Social Care
    • Time Frame: 1 year

Participating in This Clinical Trial

Inclusion Criteria

  • 80 years and older or 65 to 79 years and having at least one chronic disease and being dependent in at least one activity of daily living

Exclusion Criteria

  • acute severely sick who immediately needs the assessment of a physician (within ten minutes)
  • those with diagnosis of dementia (or severe cognitive impairment)
  • patients in palliative care

Gender Eligibility: All

Minimum Age: 65 Years

Maximum Age: N/A

Are Healthy Volunteers Accepted: No

Investigator Details

  • Lead Sponsor
    • Vardalinstitutet The Swedish Institute for Health Sciences
  • Collaborator
    • VinnVård
  • Provider of Information About this Clinical Study
    • Sponsor
  • Overall Official(s)
    • Katarina Wilhelmson, MD,PhD, Principal Investigator, Göteborg University

Clinical trials entries are delivered from the US National Institutes of Health and are not reviewed separately by this site. Please see the identifier information above for retrieving further details from the government database.

At, we keep tabs on over 200,000 clinical trials in the US and abroad, using medical data supplied directly by the US National Institutes of Health. Please see the About and Contact page for details.