Preventing hospital readmissions and loss of functional ability in high risk older adults: a randomised controlled trial

INTERVENTION: Intervention 1. Gerontic Nurse (GN) comprehensive assessment within 72 hours of hospital admission, discharge planning, home visit within 72 hours from discharge, telephone follow‐up care weekly for 4 weeks then monthly for 24 weeks post‐discharge. Intervention 2. Physiotherapist comprehensive assessment within 72 hours of hospital admission, individualised exercise program commencing within 72 hours of hospital admission. Intervention 3. Gerontic Nurse (GN) and Physiotherapist comprehensive assessment within 72 hours of hospital admission, individualised exercise program commencing within 72 hours of hospital admission, discharge planning (GN), home visit within 72 hours from discharge (GN), telephone follow‐up care weekly for 4 weeks then monthly for 24 weeks post‐discharge (GN). CONDITION: Hospital readmissions and loss of functional ability in older adults at high risk of hospital readmission PRIMARY OUTCOME: Cost effectiveness, using measures of cost of care, cost of unplanned health service use, costs related to decreased functional ability and loss of independence in activities of daily living Functional Ability, as measured with Instrumental Activities of Daily Living Scale, Activities of Daily Living Scae, and Walking Impairment Questionnaire (Modified) Hospital readmissions and unplanned health service use (Emergency Department visits, emergency visits to General Practitioners or other health professionals) SECONDARY OUTCOME: Physical strength and endurance, measured with grip strength, Timed Get Up and Go Test, Berg Balance Scale, 6 metre walk test Psychosocial outcomes, as measured with the Geriatric Depression Scale, Medical Outcomes Study Social Support Scale and Chronic Disease Self‐Efficacy Scales Quality of Life, using the SF‐12v2 INCLUSION CRITERIA: 1. Aged 65 years or older 2. Admitted to a hospital wards with a medical (i.e. non‐surgical) diagnosis 3. Have at least one of the following known risk factors for hospital readmission: a. aged 75 years or older b. live alone c. poor social support available at home d. 2 or more hospital admissions within the previous 6 months e. previous hopsitalisation in the past 30 days f. moderate to severe functional impairment g. history of depression