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medical follow-up appointment for Frailty
N/A
Waitlist Available
Led By Patrick M Archambault, MD, MSc
Research Sponsored by Laval University
Eligibility Criteria Checklist
Specific guidelines that determine who can or cannot participate in a clinical trial Must have
Be older than 65 years old
Timeline
Screening 3 weeks
Treatment Varies
Follow Up each 3 months, during 4 years (12)
Awards & highlights
Study Summary
This trial will help four hospitals in Chaudière-Appalaches improve care for elderly patients by adapting best practices for transitioning them back into the community.
Eligible Conditions
- Frailty
- Health Care Utilization
- Emergency
- Transition
Timeline
Screening ~ 3 weeks3 visits
Treatment ~ Varies
Follow Up ~ each 3 months, during 4 years (12)
Screening ~ 3 weeks
Treatment ~ Varies
Follow Up ~each 3 months, during 4 years (12)
Treatment Details
Study Objectives
Outcome measures can provide a clearer picture of what you can expect from a treatment.Primary outcome measures
Change of 30-day ED visit rate
Change of 30-day hospital readmission
Secondary outcome measures
1- Care Transitions Measure (CTM3) - Patient outcome
1- change Hospital/ED length of stay - Hospital-level outcome
1-Clinical-level process outcome - Proportion of patients assigned a GEM Nurse
+12 moreTrial Design
3Treatment groups
Experimental Treatment
Active Control
Group I: Phase IC (Study description)Experimental Treatment7 Interventions
Results from each center will be analysed over time. Guided by previous work in healthcare governance, the investigators will analyze the impact of the sequential interventions within the context of a major health reform in Quebec aiming at implementing an integrated health system and within the PI program's overall goal of creating a Learning Health System. This will be accomplished by conducting a comparative case study across the four study sites to compare the barriers, facilitators and local solutions implemented to gain a better understanding about how the ACE program could eventually be scaled up elsewhere.
Group II: Phase I-B (Implementation):Experimental Treatment7 Interventions
The investigators will implement the context-adapted ACE program with the support of administrators and local implementation teams who will have the responsibility to roll out the different elements of the intervention within their respective hospitals. It may include a series of systematic pre-discharge, post-discharge and across transitions period interventions for eligible patients: 1) a GEM nurse to support patients during the post-discharge transition period, 2) pre- and post-hospitalization medication list reconciliation, 3) systematic discharge summaries given to patients and/or caregiver, and sent to their family physician, 4) a planned follow-up appointment with their family physician, 5) a systematic follow-up phone call, 6) access to wiki-based patient-oriented KT tools, 7) access to a community-based telemonitoring service.
Group III: Phase I-A (Local project set-up)Active Control1 Intervention
An executive committee will oversee the entire project. This committee, led by the nominated PI and Director of Nursing, will meet every 4 weeks during this four-year project. The team may include, depending on the hospital site: an administrator, the ED Director, the ED Head nurse, a community and/or hospital-based geriatric nurse specialist, an ED physician, a hospitalist, a geriatrician, a family physician, a home care nurse/coordinator, an inpatient unit manager, the research coordinator, and a local patient/caregiver. Each local team will be responsible for selecting and implementing the ACE intervention(s) best suiting their milieu, and will include locally identified champions to lead the local implementation.
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Who is running the clinical trial?
Laval UniversityLead Sponsor
420 Previous Clinical Trials
168,727 Total Patients Enrolled
1 Trials studying Frailty
695 Patients Enrolled for Frailty
Patrick M Archambault, MD, MScPrincipal InvestigatorLaval University
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