Cross-sectoral follow-up after hospital discharge from a geriatric ward: a study protocol of a randomised controlled...

Advancing age is associated with multimorbidity, polypharmacy and functional impairments and older adults with these characteristics are at increased risk of acute admission and readmission. Readmission rate of geriatric patients is high, especially within the first week after discharge. Previous studies on transitional care interventions have mainly showed positive effects, but no study has assessed the effect of a home visit done jointly by a geriatric nurse and a community nurse, with a systematic review of health functions, objective clinical assessment and bedside blood analyses.

A single-centre two-arm parallel group randomised controlled trial using permuted block randomisation will be conducted. Randomisation occurs at discharge. The intervention consists of a follow-up visit within 2-5 days by a geriatric nurse and a community nurse. A systematic review of bodily functions is carried out, and solutions of identified problems are discussed taking into consideration the patient's view. If the patient shows signs of worsened health since discharge vital status and bedside blood analyses using point-of-care-testing (POCT) can be carried out at the discretion of the geriatric nurse. As required the patients will be conferred with a senior geriatrician by video consultation. The patient's primary care physician is invited to participate online. The control group will receive usual discharge. Endpoints are readmission, mortality rates and financial costs. User perspectives include focus group interviews with patients, geriatric nurses, community nurses, geriatricians and primary care physicians.

The intervention is multifactorial to match the needs of complex geriatric patients. We will thus not be able to discern, which part of the intervention has the greatest impact, but the intervention will encompass most of the clinical situation that may potentially lead to acute readmission. If a positive effect is found the intervention may be scaled up to include all departments discharging vulnerable geriatric patients, as well as implemented in guidelines for the discharge of older medical patients.

ClinicalTrials.gov, Identifier: NCT05139823, Registered 1 December 2021.