Enhanced Primary Care for Elderly

Overview

The present health care situation for the elderly in many countries is insufficient and not designed according to the health care needs of the aged population. In a pragmatic multicenter primary care setting (n= 1600), the investigators use an evidence based prediction model to find elderly (75+) with high risk for complex medical care or hospitalization and apply a differentiated and directed medical and social care to this risk group, in comparison to usual care. The intervention will include all the latest evidence based tools in the care of elderly (multi-professional team, social support, medical care home-visits, telephone support, general practitioner visits, etc). The project has high potential impact on the development of future care of elderly.

In addition to the intervention study, several academic sub-studies focusing on patient's perspective, professional roles, equality, implementation and governance management of health care will be performed.

Full Title of Study: “Enhanced Primary Care for Elderly: A Multicenter Pragmatic Clinical Trial Where Older People With Great Needs Are Predicted and Given Personalized Primary Care”

Study Type

  • Study Type: Observational
  • Study Design
    • Time Perspective: Prospective
  • Study Primary Completion Date: December 31, 2019

Detailed Description

The current project is a multidisciplinary research project covering several aspects of a shift in elderly care, with outcome measures not only related to primary medical or functional measures. The analyses will widen the view to overall societal costs and effects of changes in key institutions of social security as well as to hidden mechanisms in the governance system of care and health care of elderly.

The primary aim of the present study is to investigate the extent to which a differentiated (personalized) and targeted primary care intervention provided to a statistically predicted risk population of elderly, results in care that is more effective and of higher quality than that of a control group receiving standard care. In a pragmatic multicenter primary care setting (n= 1600), an evidence based prediction model to find elderly (75+) with high risk for complex medical care or hospitalization is used followed by a differentiated and directed medical and social care to this risk group, in comparison to usual care. The intervention will include all the latest evidence based tools in the care of elderly (multi-professional team, social support, medical care home-visits, telephone support, general practitioner visits, etc).

The investigators also aim to study the care model in a broader sense; experiences of the elderly, their social networks and diversity. Finally, the project will also investigate how the health care system, from specific health care professionals (primary care nurses, doctors, para-medical staff) to management levels and politicians influence the implementation of the present and future care models. One specific subproject focuses on the mechanisms behind the inability of steak holders/politicians and top administrative executives to find efficient governance principals for elderly care and health care, despite already available knowledge sources.

Interventions

  • Other: Multi-disciplinary and personalized primary care
    • Team-based primary care where nurse, GP, social-worker, physiotherapist, occupational therapist evaluate and give treatment

Arms, Groups and Cohorts

  • Predicted and personalized primary care
    • Elderly 75 years of age and older in primary care with high risk of being fragile and future risk of needing hospital care that receives personalized primary care
  • Predicted but with treatment as usual
    • Elderly 75 years of age and older in primary care with high risk of being fragile and future risk of needing hospital care that receives treatment as usual

Clinical Trial Outcome Measures

Primary Measures

  • Hospital care days
    • Time Frame: June 1st 2017 – May 31 st 2019
    • The number of days in hospital

Secondary Measures

  • Hospital care occasions
    • Time Frame: June 1st 2017 – May 31 st 2019
    • Number of occasions in hospital care
  • Health related quality of life
    • Time Frame: June 1st 2017 – May 31 st 2019
    • Measured as EQ-5D scores
  • Costs for health care
    • Time Frame: June 1st 2017 – May 31 st 2019
    • The total costs for health care measured in USD
  • Mortality
    • Time Frame: June 1st 2017 – May 31 st 2019
    • Number of deaths during the study period

Participating in This Clinical Trial

Inclusion Criteria

  • Age 75 years and older living in county of Östergötland

Exclusion Criteria

  • No exclusion criteria

Gender Eligibility: All

Minimum Age: 75 Years

Maximum Age: 110 Years

Investigator Details

  • Lead Sponsor
    • Region Östergötland
  • Provider of Information About this Clinical Study
    • Principal Investigator: Jan Marcusson, MD, senior consultant, professor – Region Östergötland
  • Overall Official(s)
    • Jan Marcusson, MD, PhD, Principal Investigator, Linkoeping University
  • Overall Contact(s)
    • Jan Marcusson, Professor, +46705717033, jan.marcusson@liu.se

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 TrialBulletin.com, 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.