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A continuum of care for frail elderly people

The intervention “A continuum of care for frail elderly people” takes place in the municipality of Mölndal, Sweden, including municipal health and social care, the hospital of Mölndal, and primary care. The study has a descriptive analytical and experimental design. The intervention is performed as a randomised controlled trial. The participants were randomised to two study arms, one intervention group and one control group. Intervention group: The intervention includes an early geriatric assessment, early family support, a case manager in the community with a multi-professional team and the involvement of the elderly people and their relatives in the planning process. Control group: The control group received conventional care and follow up. The study group included 161 elderly people who sought care at the emergency department at Mölndal Hospital during the period October 2008 to June 2010 and who were discharged to their own homes in the municipality of Mölndal. Inclusion criteria were age 80 and older or 65 to 79 with at least one chronic disease and dependent in at least one activity of daily living. A baseline interview and assessment were done within a week of discharge. In some cases it was not possible to do the baseline interview so soon, mostly because the frail elderly person not having enough strength. Follow up data were collected at 3, 6 and 12 months, and after 2 years following the baseline measurement. Purpose: The overall aim of the study was to implement the intervention and thereby create a continuum of care for frail elderly people, from the emergency ward to their own homes, resulting in a better quality of care and higher cost-effectiveness. Another aim was to study the implementation process of the intervention programme. The dataset includes the participants in the intervention group and the control group, a total of 161 participants. The baseline intervention was carried out between October 2008 and June 2010, and follow ups at 3, 6 and 12 months.

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Version 1
doris
University of Gothenburg