AdvantAGE: Implementation and Evaluation of an Interprofessional Tranistional Care Model for Frail Older Adults

AdvantAGE: Implementation and Evaluation of an Interprofessional Transitional Care Model for Frail Older Adults at the University Department of Geriatric Medicine FELIX PLATTER

This clinical trial at the University Department of Geriatric Medicine FELIX Platter in Basel, Switzerland, is designed to evaluate a new transitional care model aimed at helping frail older adults after they get discharged from the hospital. The AdvantAGE study aims to explore the following questions:

• Does the new care model help reduce the number of patients who need to return to the hospital within 90 days?
• How effective is the implementation of this care model?

Participants in the trial will be followed by advanced practice nurses for up to 90 days after hospital discharge. The patients and their caregivers will receive support in coordinating care, managing medications, and learning to manage the patient's health conditions on their own. Additionally, they will have the opportunity to engage in discussions about advanced care planning.

Inclusion Criteria:

• Currently admitted to the acute or rehabilitation ward of University Department of Geriatric Medicine
• Reside in Basel-Stadt
• Possess the ability to speak and comprehend the German language
• Scheduled to be discharged to their home
• 65 years or older
• Identified by a clinician as having a high risk of deterioration due to frailty

Additionally, participants must meet at least one of the following criteria:

• diagnosed with a complex chronic disease requiring support in self-management and disease management, or
• facing socially challenging situations such as living alone without a supportive network or lacking a GP, or
• admitted for an acute illness with a brief hospital stay (e.g., infection, cardiac decompensation) and need support in self- and disease management, and continuity of the therapy plan, including close monitoring.

Exclusion Criteria:

• residing in a nursing home or being newly admitted to one
• lacking informal caregivers and exhibiting severe cognitive impairment (MMS ≤23)
• scoring <50 on the motoric domain of the Functional Independence Measure (FIM)
• having a psychiatric disorder that significantly impacts their ability to manage daily life at time of the discharge