Integration of health and social care for older people - developing and evaluating a model for seamless care transitions

Research problem and specific questionsCoordination of healthcare activities is of particular importance for older people in need of geriatric care as they often have multiple conditions and health related needs, requiring  care from several providers.

The overall aim of this research project is to introduce and evaluate a person-centered care transition model that is currently being developed through co-creation with end-users to improve the coordination of care after discharge from geriatric inpatient care.

The project is divided in three phases with the following research questions: (1) is the new care transition model feasible in a local setting? (2) is the care transition model effective when evaluated in a cluster randomized-controlled trial (RCT)? (3) what are the prerequisites for implementation and how do patients, next of kin and staff experience the care transitions process?Data and methodPhase I is a feasibility study where the new model will be evaluated in terms of fidelity, applicability and acceptability using focus groups, individual interviews and questionnaires.

We will also evaluate the model’s preliminary effect on total costs after discharge, their distribution between payers, and rate of readmission using register data.

In phase II and III a refined model (based on the results from the feasibility study) will be introduced and evaluated with an effect and process evaluation using the same type of methods as in phase I.

The primary outcome in the cluster RCT will be total costs.Societal relevance and utilizationThis proposal targets the societal challenge of providing coordinated services between social services and healthcare to an aging population in a fragmented system.

If coordination of care between different responsible providers of health and social care is improved, it may have significant positive impact for the older adults, involved staff, and the society.

This project takes an overarching approach and evaluates costs across the health and social care system.Plan for project realizationFOU nu (asset manager) has a close collaboration with the geriatric departments in the region, the primary care centres and units within the municipalities as well as with patient representative organizations that we are collaborating with in the ongoing project.

This, as well as ongoing collaborations with other R&D-units within the region, gives us an excellent possibility to ensure that the project is realized as described.