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Continuum of care; From intervention study (RCT) to research of full-scale implementation of continuum of care for frail older people

Research project
Inactive research
Project owner
Institute of Neuroscience and Physiology

Short description

Continuum of care - from intervention study to research of full-scale implementation of continuum of care for older frail persons consists of two completed projects; Continuum of care for elderly people from the emergency ward to their own home and full-scale implementation of the continuum of care.

The aim was in project 1) to create a continuum of care for frail older people, from the emergency ward to their own home and to evaluate the project in a randomized design and to implement and evaluate 2) the impact of a full-scale implementation of the continuum of care (project 1).

The first project was completed in 2016 and the second project was completed in 2019. Five dissertations and about 25 articles have been published in total within the projects. Both projects are described in more detail below.

Continuum of care- from emergency ward to own home

The aim was to create a continuum of care for frail older people, from the emergency department to their own home. It was conducted as a randomised controlled trial with two study arms (1) in combination with qualitative methods.

The project has resulted in methods for better continuity when frail older people seek acute care. The work method supports older people to maintain their independence and self-determination in their own homes. Moreover, the study showed that integrated care doubled the chances of being independent in ADL for up to 12 months when compared to a control group. Consequently, the intervention could support frail older people to age well at home, a benefit for both the older people themselves and for the society (2).

The work method  has resulted in care managers in the community, screening and geriatric competence at emergency ward and care planning being conducted in the older persons owns homes by collaboration across organisations. 

Four dissertations and about 21 articles have been published within the project.

(1) Continuum of care for frail elderly people: Design of a randomized controlled study of a multi-professional and multidimensional intervention targeting frail elderly people. 
Wilhelmson K, Dunér A, Eklund K, Gosman-Hedström G, Blomberg S, Hasson H, Gustafsson H, Landahl S, Dahlin-Ivanoff S
BMC Geriatr 2011 May;11:24

(2) One-year outcome of frailty indicators and activities of daily living following the randomised controlled trial; "continuum of care for frail older people". 
Eklund K, Wilhelmson K, Gustafsson H, Landahl S, Dahlin-Ivanoff S.
BMC Geriatr 2013 Jul; 13(1)

From intervention study to research of full-scale implementation of continuum of care for frail older persons

The aim was to evaluate a full-scale implementation of the programme “Continuum of care for frail older". The programme targets frail older people, 75 years of age or older. The study evaluates if the programme identifies frail older people with complex needs and how sustainable the benefits are for the target group when the programme is conducted in “real life”.

The programme is also evaluated from a staff perspective, with regards to how it has been conducted in different care organisations, and how the conduct could be understood in terms of facilitators and barriers in the organisation. Both qualitative and quantitative data are used to get an understanding of the implementation process. The implementation had effect on frailty, self-rated health (3) and life satisfaction (4).

The findings also show that there is a need for improvements with regards to collaboration between staff and organisations to ensure a continuum of integrated care and frail older people’s participation in the discharge process. Insufficient knowledge represented barriers for collaboration, in favour for organisationally related norms and values and professional boundaries.

The study is important, not only to visualise older people’s needs of health and social care, and how these needs could be met, but also for understanding how to apply current knowledge in health and social care. The findings are expected to optimize future complex  interventions and lead to improved care, support and rehabilitation of frail older people with complex needs. One dissertation and four papers have so far been published in the project.

3) From Intervention Trial to Full-scale Implementation Research: Positive Tendencies for Frailty and Self-rated Health in Frail Older People.
Hammar, Isabelle & Westgard, Theresa & Eklund, Kajsa & Wilhelmson, Katarina & Dahlin-Ivanoff, Synneve. (2018).
Geriatrics and Gerontology International. 2018. 10.29011/2577-0748. 

4) Effect of a care process programme on frail older people’s life satisfaction.
Berglund H, Gustafsson S, Ottenvall Hammar I, Faronbi J, Dahlin‐Ivanoff S.
Nursing Open. 2019;6:1097–1104.