← Back to Search

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)

This trial's timeline: 3 weeks for screening, Varies for treatment, and each 3 months, during 4 years (12) for reporting.

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 more

Trial 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.

Do I qualify?Apply below to find out

Find a Location

Who is running the clinical trial?

Laval UniversityLead Sponsor

417 Previous Clinical Trials

168,272 Total Patients Enrolled

1 Trials studying Frailty

695 Patients Enrolled for Frailty

Patrick M Archambault, MD, MScPrincipal InvestigatorLaval University

Frequently Asked Questions

These questions and answers are submitted by anonymous patients, and have not been verified by our internal team.

Are there still openings available to participate in this research?

"Per the information posted on clinicaltrials.gov, this research study is currently accepting participants. It was first published in January 21st of 2019 and received its last update November 1st of the same year."

Answered by AI

How many individuals are being monitored in this research?

"Affirmative. Clinicaltrials.gov reports that this clinical trial, which was advertised on January 21st of 2019 and updated most recently in November 1st of the same year, is currently inviting participants to join. A total of 4000 patients are required for the study from a single medical centre."

Answered by AI

What aims is this clinical research endeavor striving to accomplish?

"This medical trial aims to measure the alteration of 30-day hospital readmission rate over 4 years. Secondary objectives encompass two clinical process outcome parameters, such as Proportion of patients/caregiver/physician receiving discharge summary and Hospital/ED length of stay; furthermore, ED admission rate is also evaluated by collecting data from various databases like MedGPS, Logibec Montreal Canada (RAMQ) physician billing database and MedECHO in addition to INESSS."

Answered by AI

Recent research and studies

Journal of Clinical EpidemiologyJournal

A Prospective Cohort Study Found That Provider and Information Continuity Was Low After Patient Discharge from Hospital

van Walraven, Carl, Monica Taljaard, Chaim M. Bell, Edward Etchells, Ian G. Stiell, Kelly Zarnke, and Alan J. Forster. 2010. “A Prospective Cohort Study Found That Provider and Information Continuity Was Low After Patient Discharge from Hospital”. Journal of Clinical Epidemiology. Elsevier BV. doi:10.1016/j.jclinepi.2010.01.023.

Healthcare QuarterlyJournal

Toward Safer Transitions: How Can We Reduce Post-discharge Adverse Events?

Dhalla, Irfan, Tara O'Brien, Francoise Ko, and Andreas Laupacis. 2012. “Toward Safer Transitions: How Can We Reduce Post-discharge Adverse Events?”. Healthcare Quarterly. Longwoods Publishing. doi:10.12927/hcq.2012.22839.

formation/NLM/NIH, NCBI. “Gprobe”. 2017. Web. <https://github.com/ncbi/gprobe>..Journal

Gprobe

Information/NLM/NIH, NCBI. 2017. “Gprobe”. GitHub repository. https://github.com/ncbi/gprobe.

The Journals of Gerontology Series A: Biological Sciences and Medical SciencesJournal