Transitional CareAdvantAGENCT06190288
AdvantAGE: Implementation and Evaluation of an Interprofessional Tranistional Care Model for Frail Older Adults
A study testing Transitional care model in people with Transitional Care and Multimorbidity, run by Thekla Brunkert at 1 site in Switzerland.
Trial summary
This clinical trial at the University Department of Geriatric Medicine FELIX Platter in Basel, Switzerland, is designed to evaluate a new transitional care model aimed at helping frail older adults after they get discharged from the hospital. Read more about this study
- Who is it for?
- Ages 65 years and older
- Conditions the study is for
- Transitional Care, Multimorbidity, Geriatric Care
- What is being tested?
- Transitional care model
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 250 participants
- Where
- 1 siteSwitzerland
- Study dates
- 8 Jan 2024to 30 Jun 2026
- 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
- Currently admitted to the acute or rehabilitation ward of University Department of Geriatric Medicine
- Reside in Basel-Stadt
- Possess the ability to speak and comprehend the German language
- Scheduled to be discharged to their home
- 65 years or older
- Identified by a clinician as having a high risk of deterioration due to frailty
Show all 10Show fewer
- Additionally, participants must meet at least one of the following criteria:
- diagnosed with a complex chronic disease requiring support in self-management and disease management, or
- facing socially challenging situations such as living alone without a supportive network or lacking a GP, or
- admitted for an acute illness with a brief hospital stay (e.g., infection, cardiac decompensation) and need support in self- and disease management, and continuity of the therapy plan, including close monitoring.
Who cannot join
- residing in a nursing home or being newly admitted to one
- lacking informal caregivers and exhibiting severe cognitive impairment (MMS ≤23)
- scoring <50 on the motoric domain of the Functional Independence Measure (FIM)
- having a psychiatric disorder that significantly impacts their ability to manage daily life at time of the discharge
Trial locations and contacts
1 site in 1 country.
Switzerland1 site, 1 recruiting
- Recruiting
Universitäre Altersmedizin FELIX PLATTER
Basel, 4055
Mario Ernst, MSc, +41613264481, mario.ernst@felixplatter.ch
About this study
Official title: AdvantAGE: Implementation and Evaluation of an Interprofessional Transitional Care Model for Frail Older Adults at the University Department of Geriatric Medicine FELIX PLATTER
This clinical trial at the University Department of Geriatric Medicine FELIX Platter in Basel, Switzerland, is designed to evaluate a new transitional care model aimed at helping frail older adults after they get discharged from the hospital. The AdvantAGE study aims to explore the following questions:
- Does the new care model help reduce the number of patients who need to return to the hospital within 90 days?
- How effective is the implementation of this care model?
Participants in the trial will be followed by advanced practice nurses for up to 90 days after hospital discharge. The patients and their caregivers will receive support in coordinating care, managing medications, and learning to manage the patient's health conditions on their own. Additionally, they will have the opportunity to engage in discussions about advanced care planning.
- Conditions
- Transitional Care, Multimorbidity, Geriatric Care
- Being tested
- Transitional care model
- Keywords
- Transitional Care, Frailty, Rehospitalisation, Geratric Care
- Medical subject headings
- Frailty
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
Transitional care modelOther
Also called AdvantAGE
A newly developed care model to support frail older adults during their transition from hospital to home.
| Study group | Role | What they receive |
|---|---|---|
| Intervention group | Experimental | The intervention includes five core elements provided by a multiprofessional team: (1) continuous support for patients and caregivers; (2) care coordination with primary care providers;(3) visits at patients' homes; (4) medication- and self-management with patients and caregivers; and (5) proactive advanced care planning. Patients will receive specialized support including home visits up to 90 days after hospital discharge. Receives: Other: Transitional care model |
What is being measured
The primary outcome is the main question the study is designed to answer.
90-days rehospitalization rate
Number of unplanned hospital admissions of any kind happening within 90 days after discharge
Measured: 90 days post-discharge
Secondary outcomes (6)
30-days rehospitalization rate
Number of unplanned hospital admission of any kind happening within 30 days after discharge
Measured: 30 days post-discharge
Time to readmission
Number of days between hospital discharge and unplanned hospital admission
Measured: Up to 90 days post-discharge
Number of emergency room visits
Number of emergency room visits (with or without hospital admission) within 90 days after discharge
Measured: 90 days post-discharge
Time to emergency room visit
Number of days between hospital discharge and emergency room visit
Measured: Up to 90 days post-discharge
Patient's health-related quality of life
The EuroQoL-5D-5L is used to assess the health-related quality of life in patients at three time points. Prior to hospital discharge, 7 days and 90 days after hospital discharge or if the patient completed the intervention
Measured: Up to 90 days post-discharge
Patient satisfaction questionnaire
Satisfaction regarding intervention participation
Measured: up to 90 days post-discharge
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted5 Jan 2024
- Study start8 Jan 2024
- Primary completion30 Jun 2026 (estimated)
- Study completion30 Jun 2026 (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 Transitional CareStudies of the same condition, open and under way.
- 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
- Health services research
- Allocation
- Not applicable
- Intervention model
- Single group
- Model description
- Hybrid effectiveness-implementation study (type 1)
- Masking
- None (open label)
- Enrolment
- 250 participants (estimated)
Sponsor and investigators
- Lead sponsor
- Thekla Brunkert
- Sponsor type
- University, hospital or other
- Collaborators
- Health Department of the Canton of Basel-Stadt
- Responsible party
- Sponsor-investigator, Thekla Brunkert, University Department of Geriatric Medicine FELIX PLATTER
- Investigators
- Thekla Brunkert, PhD, Principal investigator, Universitäre Altersmedizin FELIX PLATTER
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT06190288
- Sponsor's protocol ID
- 02072
- Acronym
- AdvantAGE
- Status last verified
- Feb 2024
- First submitted
- 19 Dec 2023
- Last updated
- 2 Feb 2024
- Results posted
- No
- Data monitoring committee
- Yes
- FDA-regulated drug
- No
- FDA-regulated device
- No
- Individual data sharing
- No
Publications
Brunkert T, Pfundstein I, Nickel CH, Lampert ML, Trutschel D, Mauthner O. AdvantAGE: Implementation and Evaluation of an Interprofessional Transitional Care Model for Frail Older Adults-Protocol of an Effectiveness-Implementation Hybrid Study. J Adv Nurs. 2025 Aug;81(8):5130-5142. doi: 10.1111/jan.16745. Epub 2025 Jan 26.
PubMed 39865439
Study at a glance
From the registry record, last updated by the sponsor on 2 Feb 2024. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- AdvantAGE: Implementation and Evaluation of an Interprofessional Transitional Care Model for Frail Older Adults at the University Department of Geriatric Medicine FELIX PLATTER
- ClinicalTrials.gov ID
- NCT06190288
- Acronym / sponsor ID
- AdvantAGE / 02072
- Conditions
- Transitional Care, Multimorbidity, Geriatric Care
- Keywords
- Transitional Care, Frailty, Rehospitalisation, Geratric Care
- Study type
- Interventional
- Recruitment status
- Unknown status
- Enrolment
- 250 participants (estimated)
- Lead sponsor
- Thekla BrunkertUniversity, hospital or other
- Collaborators
- Health Department of the Canton of Basel-Stadt
- Study start
- 8 Jan 2024 (actual)
- Primary completion
- 30 Jun 2026 (estimated)
- Study completion
- 30 Jun 2026 (estimated)
- First posted
- 5 Jan 2024 (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.
This clinical trial at the University Department of Geriatric Medicine FELIX Platter in Basel, Switzerland, is designed to evaluate a new transitional care model aimed at helping frail older adults after they get discharged from the hospital. The AdvantAGE study aims to explore the following questions:
- Does the new care model help reduce the number of patients who need to return to the hospital within 90 days?
- How effective is the implementation of this care model?
Participants in the trial will be followed by advanced practice nurses for up to 90 days after hospital discharge. The patients and their caregivers will receive support in coordinating care, managing medications, and learning to manage the patient's health conditions on their own. Additionally, they will have the opportunity to engage in discussions about advanced care planning.
Study design
- Primary purpose
- Health services research
- Allocation
- Not applicable
- Intervention model
- Single group
- Masking
- None (open label)
- Number of arms
- 1
- Model description
- Hybrid effectiveness-implementation study (type 1)
| Arm | Type | Receives |
|---|---|---|
| Intervention group | Experimental | Other: Transitional care modelThe intervention includes five core elements provided by a multiprofessional team: (1) continuous support for patients and caregivers; (2) care coordination with primary care providers;(3) visits at patients' homes; (4) medication- and self-management with patients and caregivers; and (5) proactive advanced care planning. Patients will receive specialized support including home visits up to 90 days after hospital discharge. |
Who may qualify
- Ages
- 65 years and older
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Older adult
Key inclusion criteria (10 listed)
- Currently admitted to the acute or rehabilitation ward of University Department of Geriatric Medicine
- Reside in Basel-Stadt
- Possess the ability to speak and comprehend the German language
- Scheduled to be discharged to their home
- 65 years or older
Key exclusion criteria (4 listed)
- residing in a nursing home or being newly admitted to one
- lacking informal caregivers and exhibiting severe cognitive impairment (MMS ≤23)
- scoring <50 on the motoric domain of the Functional Independence Measure (FIM)
- having a psychiatric disorder that significantly impacts their ability to manage daily life at time of the discharge
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 |
|---|---|---|
| Transitional care modelAlso: AdvantAGEA newly developed care model to support frail older adults during their transition from hospital to home. | Other | Intervention group |
Primary outcome
90-days rehospitalization rate
Time frame: 90 days post-discharge
Number of unplanned hospital admissions of any kind happening within 90 days after discharge
6 secondary outcomes
30-days rehospitalization rate
Time frame: 30 days post-discharge
Time to readmission
Time frame: Up to 90 days post-discharge
Number of emergency room visits
Time frame: 90 days post-discharge
Time to emergency room visit
Time frame: Up to 90 days post-discharge
Patient's health-related quality of life
Time frame: Up to 90 days post-discharge
Patient satisfaction questionnaire
Time frame: up to 90 days post-discharge
Results and safety
Results are not available in the source record.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 2 Feb 2024.
- Derived from this study: PubMed 39865439Brunkert T, Pfundstein I, Nickel CH, Lampert ML, Trutschel D, Mauthner O. AdvantAGE: Implementation and Evaluation of an Interprofessional Transitional Care Model for Frail Older Adults-Protocol of an Effectiveness-Implementation Hybrid Study. J Adv Nurs. 2025 Aug;81(8):5130-5142. doi: 10.1111/jan.16745. Epub 2025 Jan 26.
- project homepage (in German)Link provided by the sponsor.
- Individual participant dataSharing planned: No
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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.
Thekla Brunkert, PhD principal investigator
Universitäre Altersmedizin FELIX PLATTER
1 site in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A study testing Transitional care model in people with Transitional Care and Multimorbidity, run by Thekla Brunkert at 1 site in Switzerland.
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 10 inclusion and 4 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 2 Feb 2024. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 1 site in Switzerland. Whether a site is taking part right now should be confirmed with that site. See every site.
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?
Contact Mario Ernst (+41 61 326 44 81, mario.ernst@felixplatter.ch), or a site near the patient. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
90-days rehospitalization rate (time frame: 90 days post-discharge). 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 NCT06190288, 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 2 Feb 2024.