Extended Cross-sectoral Nurse Follow-up After Discharge From a Geriatric WardNCT05139823
Extended Cross-sectoral Nurse Follow-up After Discharge From a Geriatric Ward - Benefits and Challenges. A Mixed-method Study
A study testing geriatric follow-up home visit after discharge in people with Extended Cross-sectoral Nurse Follow-up After Discharge From a Geriatric Ward, run by Odense University Hospital.
Trial summary
Purpose By using both quantitative and qualitative research methods to examine the impact of a coordinated home visit by a geriatric nurse and a community (home care) nurse to vulnerable older patients recently discharged from a geriatric department. Read more about this study
- Who is it for?
- Ages 65 years and older
- Conditions the study is for
- Extended Cross-sectoral Nurse Follow-up After Discharge From a Geriatric Ward
- What is being tested?
- geriatric follow-up home visit after discharge
- Type of treatment
- Surgery or procedure
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 1,514 participants
- Where
- No sites listed yet
- Study dates
- 1 Nov 2022to 31 Oct 2025
- Phase
- Interventional
- Are there results?
- None posted in the registry
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 65 years and older
- All sexes
- No healthy volunteers
- Older adult
Who may be able to join
- Eligible participants are patients acutely admitted to G-OUH, residents in Odense Municipality, and discharged to own home with arranged home care for personal care, or discharged to permanent care in a care home.
Who cannot join
- Excluded from the study are patients discharged to a temporary skilled nursing facility, terminally ill patients with an anticipated short life expectancy, and incapacitated patients, e.g., patients with a diagnosis of dementia or persistent symptoms of cognitive impairment due to delirium during the whole in-hospital stay. Patients with a permanent address in a care home are not excluded by their type of residence unless they are mentally incapacitated.
About this study
Purpose By using both quantitative and qualitative research methods to examine the impact of a coordinated home visit by a geriatric nurse and a community (home care) nurse to vulnerable older patients recently discharged from a geriatric department. The project will address the transition between health care sectors by examining how nursing care information is communicated between sectors, and whether in-home use of digital health solutions can optimize clinical assessments leading to relevant changes in treatment plans and prevention of acute readmissions. User perspectives of both health professionals, patients and their relatives will be applied.
In the quantitative study the primary endpoints are acute readmissions within 30-days and 90-days. The secondary endpoints are 1 year-mortality, numbers of quantitative clinical assessments (e.g., clinical assessment scores, vital signs, POCT) and their associations with clinical decision making, time to readmission, days out of hospital. Financial costs will be assessed.
The qualitative study will provide insight into the challenges and barriers in the transition between hospital and home and opposite as experienced by the patient. Secondly, with a user perspective (i.e. patient, relatives, health professionals) the study will provide in-depth knowledge in the personal care needs of vulnerable patients and how they can be met in a cross-sectoral collaboration between an out-going geriatric nursing team and the home care nursing team. Finally, the important identified complex areas of nursing care during transition will be described and suggested implemented in educational curricula of health professionals.
- Being tested
- geriatric follow-up home visit after discharge
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
geriatric follow-up home visit after dischargeProcedure or surgery
An appointment for a geriatric follow-up home visit is made with the patient and the municipal home care (community) nurse 2-4 days after discharge and only on weekdays. Relatives are informed about the visit and are welcome to join with the patient's acceptance. The local home care team as well as the patient's PCP receives the same digital discharge plan and discharge summary, respectively, as in the control group. While a follow-up visit is scheduled with the home care nurse, the PCP is invited to join too if available, either in person or by a video link. Administratively, the patients are treated as geriatric outpatients, with an in-home follow up instead of a visit in the Geriatric outpatient clinic.
| Study group | Role | What they receive |
|---|---|---|
| Control | No intervention | Controls receive usual care, which is a digital communication to the local home care team including a discharge care plan to the home care system, including information about the discharge diagnoses, and recommendations for particular attention to specific bodily functions and medical treatment regime. The patient's PCP receives a discharge summary from the treating hospital physician as usual. |
| Intervention | Experimental | An appointment for a geriatric follow-up home visit is made with the patient and the municipal home care (community) nurse 2-5 days after discharge and only on weekdays. Relatives are informed about the visit and are welcome to join with the patient's acceptance. The local home care team as well as the patient's PCP receives the same digital discharge plan and discharge summary, respectively, as in the control group. While a follow-up visit is scheduled with the home care nurse, the PCP is invited to join too if available, either in person or by a video link. Administratively, the patients are treated as geriatric outpatients, with an in-home follow up instead of a visit in the Geriatric outpatient clinic. Receives: Procedure: geriatric follow-up home visit after discharge |
What is being measured
The primary outcome is the main question the study is designed to answer.
Acute readmissions
Unplanned readmission within 30 days
Measured: 30 days
Secondary outcomes (3)
Readmission
Unplanned readmission within 90 days
Measured: 90 day
Mortality
1-year mortality
Measured: 1 year
Time to readmission
Hazard model of readmission with a duration of one year
Measured: 1 year
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted1 Dec 2021
- Study start1 Nov 2022 (estimated)
- Primary completion7 Dec 2024 (estimated)
- Study completion31 Oct 2025 (estimated)
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (1)Papers the sponsor has linked to this study.
- Other trials for Extended Cross-sectoral Nurse Follow-up After Discharge From a Geriatric WardStudies of the same condition, open and under way.
- More trials run by Odense University HospitalThe sponsor's other registered studies.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase N/A
- Primary purpose
- Prevention
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Model description
- Single-centre two-arm parallel group randomised controlled trial using permuted block randomisation
- Masking
- Triple blind
- Who is masked
- Care provider, Investigator, Outcomes assessor
- Enrolment
- 1,514 participants (estimated)
Sponsor and investigators
- Lead sponsor
- Odense University Hospital
- Sponsor type
- University, hospital or other
- Responsible party
- Principal investigator, Karen Andersen-Ranberg, Odense University Hospital
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT05139823
- Sponsor's protocol ID
- 21/57714
- Status last verified
- Oct 2022
- First submitted
- 18 Nov 2021
- Last updated
- 3 Nov 2022
- Results posted
- No
- FDA-regulated drug
- No
- FDA-regulated device
- No
- Individual data sharing
- No
Publications
Eriksen AV, Beck SH, Nielsen D, Thomsen K, Krone JO, Andersen-Ranberg K. Cross-sectoral follow-up after hospital discharge from a geriatric ward: a study protocol of a randomised controlled trial (G-UD). Trials. 2025 Jul 1;26(1):234. doi: 10.1186/s13063-025-08922-7.
PubMed 40598384
Study at a glance
From the registry record, last updated by the sponsor on 3 Nov 2022. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Extended Cross-sectoral Nurse Follow-up After Discharge From a Geriatric Ward - Benefits and Challenges. A Mixed-method Study
- ClinicalTrials.gov ID
- NCT05139823
- Acronym / sponsor ID
- 21/57714
- Study type
- Interventional
- Recruitment status
- Unknown status
- Enrolment
- 1,514 participants (estimated)
- Lead sponsor
- Odense University HospitalUniversity, hospital or other
- Study start
- 1 Nov 2022 (estimated)
- Primary completion
- 7 Dec 2024 (estimated)
- Study completion
- 31 Oct 2025 (estimated)
- First posted
- 1 Dec 2021 (actual)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
Purpose By using both quantitative and qualitative research methods to examine the impact of a coordinated home visit by a geriatric nurse and a community (home care) nurse to vulnerable older patients recently discharged from a geriatric department. The project will address the transition between health care sectors by examining how nursing care information is communicated between sectors, and whether in-home use of digital health solutions can optimize clinical assessments leading to relevant changes in treatment plans and prevention of acute readmissions. User perspectives of both health professionals, patients and their relatives will be applied.
In the quantitative study the primary endpoints are acute readmissions within 30-days and 90-days. The secondary endpoints are 1 year-mortality, numbers of quantitative clinical assessments (e.g., clinical assessment scores, vital signs, POCT) and their associations with clinical decision making, time to readmission, days out of hospital. Financial costs will be assessed.
The qualitative study will provide insight into the challenges and barriers in the transition between hospital and home and opposite as experienced by the patient. Secondly, with a user perspective (i.e. patient, relatives, health professionals) the study will provide in-depth knowledge in the personal care needs of vulnerable patients and how they can be met in a cross-sectoral collaboration between an out-going geriatric nursing team and the home care nursing team. Finally, the important identified complex areas of nursing care during transition will be described and suggested implemented in educational curricula of health professionals.
Study design
- Primary purpose
- Prevention
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- Triple blind (care provider, investigator, outcomes assessor)
- Number of arms
- 2
- Model description
- Single-centre two-arm parallel group randomised controlled trial using permuted block randomisation
| Arm | Type | Receives |
|---|---|---|
| Control | No intervention | –Controls receive usual care, which is a digital communication to the local home care team including a discharge care plan to the home care system, including information about the discharge diagnoses, and recommendations for particular attention to specific bodily functions and medical treatment regime. The patient's PCP receives a discharge summary from the treating hospital physician as usual. |
| Intervention | Experimental | Procedure: geriatric follow-up home visit after dischargeAn appointment for a geriatric follow-up home visit is made with the patient and the municipal home care (community) nurse 2-5 days after discharge and only on weekdays. Relatives are informed about the visit and are welcome to join with the patient's acceptance. The local home care team as well as the patient's PCP receives the same digital discharge plan and discharge summary, respectively, as in the control group. While a follow-up visit is scheduled with the home care nurse, the PCP is invited to join too if available, either in person or by a video link. Administratively, the patients are treated as geriatric outpatients, with an in-home follow up instead of a visit in the Geriatric outpatient clinic. |
Who may qualify
- Ages
- 65 years and older
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Older adult
Key inclusion criteria (1 listed)
- Eligible participants are patients acutely admitted to G-OUH, residents in Odense Municipality, and discharged to own home with arranged home care for personal care, or discharged to permanent care in a care home.
Key exclusion criteria (1 listed)
- Excluded from the study are patients discharged to a temporary skilled nursing facility, terminally ill patients with an anticipated short life expectancy, and incapacitated patients, e.g., patients with a diagnosis of dementia or persistent symptoms of cognitive impairment due to delirium during the whole in-hospital stay. Patients with a permanent address in a care home are not excluded by their type of residence unless they are mentally incapacitated.
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| geriatric follow-up home visit after dischargeAn appointment for a geriatric follow-up home visit is made with the patient and the municipal home care (community) nurse 2-4 days after discharge and only on weekdays. Relatives are informed about the visit and are welcome to join with the patient's acceptance. The local home care team as well as the patient's PCP receives the same digital discharge plan and discharge summary, respectively, as in the control group. While a follow-up visit is scheduled with the home care nurse, the PCP is invited to join too if available, either in person or by a video link. Administratively, the patients are treated as geriatric outpatients, with an in-home follow up instead of a visit in the Geriatric outpatient clinic. | Procedure or surgery | Intervention |
Primary outcome
Acute readmissions
Time frame: 30 days
Unplanned readmission within 30 days
3 secondary outcomes
Readmission
Time frame: 90 day
Mortality
Time frame: 1 year
Time to readmission
Time frame: 1 year
Results and safety
Results are not available in the source record.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 3 Nov 2022.
- Derived from this study: PubMed 40598384Eriksen AV, Beck SH, Nielsen D, Thomsen K, Krone JO, Andersen-Ranberg K. Cross-sectoral follow-up after hospital discharge from a geriatric ward: a study protocol of a randomised controlled trial (G-UD). Trials. 2025 Jul 1;26(1):234. doi: 10.1186/s13063-025-08922-7.
- Individual participant dataSharing planned: No
Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
The record lists no contact. Use the official record to reach the sponsor.
Questions about this trial
What is this clinical trial studying?
A study testing geriatric follow-up home visit after discharge in people with Extended Cross-sectoral Nurse Follow-up After Discharge From a Geriatric Ward, run by Odense University Hospital.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 1 inclusion and 1 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: status not confirmed, as of the sponsor's last update on 3 Nov 2022. Status can change between updates, so confirm with the study contact before making plans.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
Results are not available in the source record.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Acute readmissions (time frame: 30 days). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT05139823, which also lists 1 linked publication.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 3 Nov 2022.