Assessment of the Relevance of a Medico-social Care of Elderly Patients, in Relay Between Hospital and Home: Experimentation of TEMPORARY HERBERGEMENT in Retirement Home " EHPAD " in Seine-et-Marne Department

Assessment of the Relevance of a Medico-social Care of Elderly Patients, in Relay Between Hospital and Home: Experimentation of TEMPORARY HERBERGEMENT in Retirement Home " EHPAD " in Seine-et-Marne Department

The main objective is to study the impact of Temporary Hebergement (TH), as a medico-social care link between hospital and home, on the length of hospitalization in the referral services.

It's a non-interventional, multi-centre study.

The request for Temporary Hebergement must be made by the principal investigator or on the recommendation of the other doctors in the co-investigator department at least 48 hours before the discharge from hospital. The EHPAD (Retirement Home) coordinating physician and/or nurse coordinator and the social worker plan the hospitalization release for Temporary Accommodation admission. The social worker must validate with the doctors the feasibility and coherence of the project of return to home, and write a summary attached to the admission file (social report) which will be used in the final analysis of the patients' return-to-home projects included in the study.

The hospital discharge for admission to HT is made with the agreement of the hospital doctor and the host EHPAD (Retirement home). A "check-list" is established to complete the patient's chart.

Upon admission and management of the patient in Temporary Hebergement , he will be followed by his treating physician. If necessary, the on-call doctor of the department that referred the patient may be contacted in case of hospital-applicant care. A mid-term review will be planned by the EHPAD (Retirement home social) worker to anticipate situations at risk of exit blockage at Day 30. The patient will be able to benefit from physiotherapy and speech therapy on prescription by liberal professionals working in the EHPAD, as well as occupational therapy and psychomotricity on the prescription of the coordinating physician during the development of the accompanying project. In addition, the Temporary Hebergement beneficiary will be able to participate in all the social activities of the residence, according to his wishes.

The following data: Quality of Life Questionnaire for Patients (Nottingham Scale) and Caregivers (SF-36 Scale), Caregiver Helper Questionnaire for Home Patients, Caregiver Burden Scale (Zarit) , ADL and IADL scales, EHPAD Patient and Caregiver Perception Questionnaire, Study Acceptability Questionnaire for Included Topics, Patient Comorbidity Evaluation Scale (Charlson) and Socio-Dataeconomic) are collected retrospectively, at Day 0 (inclusion), at Day 15, Day 30, Day 90 and Day 180 which corresponds to the end of the follow-up of patients provided for in the protocol

Inclusion Criteria:

• Patient verbally expressing his non-opposition to participation in the study and documented in the medical record by the physician
• Hospitalized in hospitals selected as recruiting centers
• Whose condition is considered compatible by the clinician with discharge from the hospital (stabilized clinical condition)
• Resident, before hospitalization, in the department of Seine-et-Marne
• Presenting a defined and feasible return home project
• whose social situation does not allow an immediate return to the home on discharge from hospital

Exclusion Criteria:

• Patient expressing his opposition to participation in the study
• Acute condition not stabilized as per physician's medical opinion
• Requiring non-insured care by the host EHPAD, namely intravenous infusions, peritoneal dialysis, palliative care, etc.
• MMS score below 18
• Exhibiting behavioural disorders with major aggression and walking