Prevention of unplanned readmissions of vulnerable elderly persons: an integrated care process for the emergency and first-line service

Prevention of unplanned readmissions of vulnerable elderly persons: an integrated care process for the emergency and first-line service

Objectives

The proposed project includes setting up an integrated care model between the hospital emergency room and the home care. The objective of the project is to develop a prototype for an integrated geriatric approach for the elderly in the emergency room in combination with a follow-up in the home situation after discharge and supported by an electronic data-exchange system.

Approach and research questions

The project will apply this care model prototype for a first time in practice and collect the necessary data for a first validation.

Firstly, a decrease in the number of unplanned, return visits to the emergency room is expected. Secondly, avoidance of unnecessary hospital admissions is expected and the effects on the number of ambulant care (day clinics) referrals, the number of home care referrals, the general daily functioning of the elderly person, and the number of admissions to a residential setting (i.e. nursing home) will also be assessed in this project. The effects described above have, in addition to added financial value, also an added social value regarding the quality of the care.
The electronic data sharing enables smooth communication and correct data sharing between the hospital and the home care, and is essential for a high-quality interdisciplinary approach. If this intervention proves effective, the concept can be distributed and generalized in other Belgian hospitals and the wider home care network.

Project partners

The partners in this project are UH Leuven as principal applicant, together with CM Leuven, Wit Gele Kruis Flemish Brabant npo, and Pyxima Inc. Goal npo is a subcontractor in this project and, in addition, the Center for Hospital and Nursing Sciences, the Emergency Healthcare Department, the Academic Center for General Medicine and the Department for Clinical and Experimental Medicine - Department for Gerontology and Geriatrics at the KULeuven all provide their expertise free of charge.