Evaluation Program of the Benefit of the Coordination of the Course of the Elderly Patient in Health Establishment - Pilot Study.

Evaluation Program of the Benefit of the Coordination of the Course of the Elderly Patient in Health Establishment - Pilot Study.

The large share of chronic diseases correlated with an aging population calls to develop necessary coordination between the hospital and non-hospital (professional of the city, home ...) to create new complementarities.

Since July 2013, the Nantes University Hospital experiences the establishment of a coordinator route patient in Gerontology. The evaluation program of the benefit of coordinating the course in elderly patients in health establishment (PROCOPES) must allow to prove the efficiency of the intervention of a coordinator route patient, following elderly patients in complex situations, both within the hospital and outside the hospital (home, nursing home,...). The objective of PROCOPES is to show the added value of an innovative position that can make the link between the hospital and the city on deemed complex situations.The pilot study results present a strong interest for health care settings, nursing home and in the world of research. It will also permit to have preliminary data for bigest studies.

Inclusion Criteria:

• Patient of 70 and more years old
• Patient living on Nantes
• Hospitalized in Nantes UH
• Patient whose the hospitalization is not relevant at the time of the request of trajectory case manager
• Patient whose the situation is complex (without solution at the time of the request)
• Patient (or legal representative) having given his assent of participation

Exclusion Criteria:

• Patient (or legal representative) refusing to participate in the protocol
• Patient whose follow-up is impossible (ex: programmed move, life expectation)