E-Health-based, trans-sectoral, geriatric health service - Geriatric Network (GerNe)

Area of Science:

• Geriatric Medicine
• Health Informatics
• Healthcare Management

Background:

• Traditional communication between geriatric clinics and general practitioners (GPs) relies on post-discharge letters.
• Multimorbid geriatric patients face high readmission rates, necessitating improved care transitions.

Purpose of the Study:

• To evaluate a novel care approach using an electronic case file (ECF) and consultation service (CS) to decrease readmissions in geriatric patients.
• To assess the impact of enhanced interprofessional communication on patient outcomes.

Main Methods:

• Implementation of an online ECF for geriatric clinics to document patient information.
• GP quarterly follow-ups and clinic-monitored CS for ongoing patient management.
• Comparison of rehospitalization rates between the intervention group and a control group using insurance data.

Main Results:

• The intervention group had a hospitalization rate of 83.1/100 person years (PY), versus 69.0/100 PY in the control group.
• No statistically significant difference in the primary endpoint (rehospitalization rate) was observed (p=0.15).
• Consultation services handled 195 contacts, primarily concerning medication management, with most initiated by clinics.

Conclusions:

• The implemented ECF and CS model did not significantly reduce 1-year rehospitalization rates for multimorbid geriatric patients.
• Despite non-significant primary outcomes, the consultation service facilitated communication, particularly regarding drug therapy.
• Further research into optimizing transitional care models, including electronic tools, is warranted to effectively reduce hospital readmissions in older adults.