Background:
Demographic changes are leading to a large number of very elderly people, most of them suffering from chronic diseases. As a consequence hospital cases increase among the 75 year olds and older people compared to the younger population. An inpatient stay often triggers restrictions in the functionality, independence and quality of life of older people. This is associated with post-stationary problems, which again lead to further hospitalisation and rehabilitation measures.
Objective:
The aim of the project is to improve the care of geriatric patients at the inpatient - outpatient care interfaces, which is to be achieved by implementing the Transitional Care Model. This should lead to a reduction of the re-introduction rate. This goal is to be achieved by clinic staff called “Pfadfinder” (scouts) who provide continuous and structured support to geriatric patients and their relatives and thus promote self-determination, responsible handling of illnesses and special requirements and contribute to the improvement of functionality, nutritional status and wound care.
The Institute for Nursing Science at Bielefeld University (Institut für Pflegewissenschaft - IPW) is responsible for the accompanying research in this project. The aim is to test the effectiveness and practicability of the proven Transitional Care Model (TCM) in the form of a randomised controlled study with a post-stationary follow-up over a period up to 12 months. Furthermore, qualitative interviews with the study participants as well as empirical data of the patients will be used to obtain differentiated information about the implementation of TCM.
Duration: 2017-2021
Project coordination: Prof. Dr. Klaus Wingenfeld
Team: Christian Köbke, Daria Wibbeke
Funding: Innovationsfond
Project partners: Universität Erlangen-Nürnberg and other