a randomised clinical trial on a comprehensive geriatric assessment and intensive home follow-up after hospital discharge the transitional care bridge一个随机临床试验在老年综合评估和强化家庭出院后随访过渡护理桥.pdfVIP

Buurman et al. BMC Health Services Research 2010, 10:296 /1472-6963/10/296 STUDY PROTOCOL Open Access A randomised clinical trial on a comprehensive geriatric assessment and intensive home follow-up after hospital discharge: the Transitional Care Bridge 1* 1 2 3 1 Bianca M Buurman , Juliette L Parlevliet , Bob AJ van Deelen , Rob J de Haan , Sophia E de Rooij Abstract Background: Older patients are at high risk for poor outcomes after acute hospital admission. The mortality rate in these patients is approximately 20%, whereas 30% of the survivors decline in their level of activities of daily living (ADL) functioning three months after hospital discharge. Most diseases and geriatric conditions that contribute to poor outcomes could be subject to pro-active intervention; not only during hospitalization, but also after discharge. This paper presents the design of a randomised controlled clinical trial concerning the effect of a pro-active, multi- component, nurse-led transitional care program following patients for six months after hospital admission. Methods/Design: Three hospitals in the Netherlands will participate in the multi-centre, double-blind, randomised clinical trial comparing a pro-active multi-component nurse-led transitional care program to usual care after discharge. All patients acutely admitted to the Department of Internal Medicine who are 65 years and older, hospitalised for at least 48 hours and are at risk for functional decline are invited to participate in the study. All patients will receive integrated geriatric care by a geriatric consultation team during hospital admission. Randomization, which will be stratified by study site and cognitive impairment, will be conducted during