Bridging the gap: creating a continuum of care through active follow-up by a case manager after discharge – a controlled study

The current landscape of acute care is highly specialized, but it falls short in meeting the comprehensive needs of frail older persons. This exposes them to avoidable risks such as loss of functional capacities causing unnecessary care needs and decreased wellbeing. The care is often fragmented, and coordination and integration between care settings have been described to be essential for the quality of care of this frail population. Coordination and integration require adequate actions from both caregivers when a person is transferred from one caregiver to another, bridging the gap and building a “health care chain”. Adding active follow-up in primary care after hospital discharge is a promising way to coordinating the care for frail older people by bridging the gap between hospital, primary health and municipality care and build a stronger integrated health care chain. To the best of our knowledge, this is an intervention that has rarely been evaluated and requires further evaluation to strengthen the evidence. This is hypothesized to safeguard the dignity of the older persons through a reorganization of care towards a continuum of care with a respectful and empathic approach that acknowledges the abilities and needs of each older person.

Coordination and integration between care settings is essential for the quality of care of frail older patients. An active follow-up by a case manager (CM) after discharge form an acute geriatric hospital ward has the potential to bridge the gap between hospital, primary and municipality care for frail older people. The study aims to evaluate the effect and implementation of a dignified and person-centered continuum of care for older persons. Specifically, it evaluates the following aspects:

• Maintaining or increasing independence in activities of daily living (as the primary outcome).
• Enhancing self-rated health and life satisfaction.
• Increasing satisfaction with health care.
• Exploring the potential for reducing health care consumption and ensuring cost-effectiveness.
• Assessing the feasibility of the intervention and study design from the perspective of frail older persons.

This is a clinical controlled study performed in 4 steps: 1) development of the content of the intervention; 2) pilot- and feasibility study; 3) full scale controlled intervention study and 4) process evaluation alongside the controlled study.

The first step focuses on content, coordination, and capacity of the primary health care centres and CMs to deliver the intervention. We will conduct four to five mixed focus groups (four to six persons/group) with responsible registered nurses at the hospital, CMs at the primary care centres, rehabilitation staff in primary care and municipalities, and persons in charge of each person’s case at the social service office. Data will be analysed using focus group methodology.

In the second step the feasibility of the study design will be assessed through progression criteria according to the recommendations of Thabane et al.: process, recruitment, retention and refusal rates, eligibility criteria, matching of participants, and data collection.

The third step is a full-scale trial. Inclusion criteria are 75 years or older, frail and admitted to a geriatric ward. In total, 150 people will be included. Participants who are discharged to a primary health care centre with a CM (intervention group) will receive an active follow-up by CM. CM will secure that discharge and care plans are executed and to address new needs. The control group will be discharged to a primary health care centre without CM, and thereby no active follow-up after discharge. The participants will be followed-up by the research team during one year, concerning dependence in activities of daily living, self-rated health, health care consumption and satisfaction with care.

The fourth step involves a process evaluation applying focus group discussions (four to six groups) with staff from hospitals, primary care, municipal care, and social care who were involved in the project. The focus groups will be performed to study opportunities and obstacles experienced with the new way of working (active follow-up after discharge of CM in primary care), how it affects the quality of care, and whether and how it has affected the possibility of dignified and fair care. Data will be analysed using focus group methodology, with focus on the collective understanding of the intervention. The focus groups will be complemented by individual interviews with eight-10 older persons to study their experiences of care, their experiences of being followed up by a CM, and how it affects their opportunities for support in daily life and living a dignified life. Interview data will be analysed using thematic analysis.