A continuum of care for frail elderly people

The intervention “A continuum of care for frail elderly people” takes place in the municipality of Mölndal, Sweden, including municipal health and social care, the hospital of Mölndal, and primary care. The study has a descriptive analytical and experimental design. The intervention is performed as a randomised controlled trial. The participants were randomised to two study arms, one intervention group and one control group.

Intervention group: The intervention includes an early geriatric assessment, early family support, a case manager in the community with a multi-professional team and the involvement of the elderly people and their relatives in the planning process.
Control group: The control group received conventional care and follow up.

The study group included 161 elderly people who sought care at the emergency department at Mölndal Hospital during the period October 2008 to June 2010 and who were discharged to their own homes in the municipality of Mölndal. Inclusion criteria were age 80 and older or 65 to 79 with at least one chronic disease and dependent in at least one activity of daily living.

A baseline interview and assessment were done within a week of discharge. In some cases it was not possible to do the baseline interview so soon, mostly because the frail elderly person not having enough strength. Follow up data were collected at 3, 6 and 12 months, and after 2 years following the baseline measurement.

Purpose:

The overall aim of the study was to implement the intervention and thereby create a continuum of care for frail elderly people, from the emergency ward to their own homes, resulting in a better quality of care and higher cost-effectiveness. Another aim was to study the implementation process of the intervention programme.

The dataset includes the participants in the intervention group and the control group, a total of 161 participants. The baseline intervention was carried out between October 2008 and June 2010, and follow ups at 3, 6 and 12 months.

干预措施“体弱老年人连续护理”在瑞典Mölndal市开展，涉及市政卫生与社会关怀、Mölndal医院及初级保健机构。该研究采用描述性分析与实验性设计，干预以随机对照试验（randomised controlled trial）的形式实施。参与者被随机分配至两个研究组：干预组与对照组。

干预组：干预内容包括早期老年评估、早期家庭支持、社区内配备跨专业团队的个案经理，以及老年人及其亲属参与护理规划过程。
对照组：对照组接受常规护理与随访。

研究组包含161名老年人，他们于2008年10月至2010年6月期间在Mölndal医院急诊科就诊，并出院返回Mölndal市的家中。纳入标准为：年龄80岁及以上；或65至79岁，且至少患有一种慢性疾病并依赖至少一项日常生活活动。

出院一周内完成基线访谈与评估。部分案例无法立即开展基线访谈，主要原因是体弱老年人体力不足。随访数据在基线测量后3、6、12个月及2年时收集。

研究目标：
本研究的总体目标是实施该干预措施，从而为体弱老年人构建从急诊病房至家庭的连续护理体系，以提升护理质量与成本效益。另一目标是研究干预方案的实施过程。

数据集包含干预组与对照组的参与者，共161人。基线干预于2008年10月至2010年6月期间开展，随访在3、6、12个月时进行。