Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Hauptstraße 5, 79104, Freiburg, Germany.
Department of Social Work, Protestant University of Applied Sciences Freiburg, 79114, Freiburg, Germany.
BMC Geriatr. 2019 Mar 4;19(1):64. doi: 10.1186/s12877-019-1088-0.
Multimorbid older adults suffering from a long-term health condition like depression, diabetes mellitus type 2, dementia or frailty are at high risk of losing their autonomy. Disability and multimorbidity in the older population are associated with social inequality and lead to soaring costs. Our local, collaborative, stepped and personalised care management for older people with chronic diseases (LoChro-Care) aims at improving outcomes for older multimorbid patients with chronic conditions whose social and medical care must be improved.
The study will evaluate the effects of LoChro-Care on functional health, depressive symptoms and satisfaction with care, resource utilisation as well as health costs in older persons with long-term conditions. The trial will compare the effectiveness of LoChro-Care and usual care in a cross-sectoral setting from hospital to community care. We will recruit 606 older adults (65+) admitted to local hospital inpatient or outpatient departments who are at risk of loss of independence. Half of them will be randomised to receive the LoChro-Care intervention, comprising seven to 16 contacts with chronic care managers (CCM) within 12 months. The hypothesis that LoChro-Care will result in better patient-centred outcomes will be tested through mixed-method process and outcome evaluation and valid measures completed at baseline and at 12 and 18 months. Cost-effectiveness analyses from the healthcare perspective will include incremental cost-effectiveness ratios.
The trial will provide evidence about the effectiveness of local, collaborative, stepped and personalised care management for multimorbid patients with more than one functional impairment or chronic condition. Positive results will be a first step towards the implementation of a systematic cross-sectoral chronic care management to facilitate the appropriate use of available medical and nursing services and to enhance self-management of older people.
German Clinical Trials Register (DRKS): DRKS00013904 ; Trial registration date: 02. February 2018.
患有长期健康问题（如抑郁症、2 型糖尿病、痴呆症或虚弱）的多病老年患者面临丧失独立性的高风险。老年人的残疾和多病与社会不平等有关，并导致成本飙升。我们当地的、协作的、阶梯式的和个性化的慢性病老年人护理管理（LoChro-Care）旨在改善需要改善社会和医疗护理的慢性疾病多患者的预后。
该研究将评估 LoChro-Care 对功能健康、抑郁症状和护理满意度、资源利用以及长期疾病老年人的健康成本的影响。该试验将在医院到社区护理的跨部门环境中比较 LoChro-Care 和常规护理的效果。我们将招募 606 名有住院或门诊风险的老年人（65 岁以上），这些老年人有丧失独立性的风险。他们中的一半将被随机分配接受 LoChro-Care 干预，包括在 12 个月内与慢性病管理师（CCM）进行 7 到 16 次联系。通过混合方法的过程和结果评估以及基线和 12 个月和 18 个月时完成的有效措施，将检验 LoChro-Care 将导致更好的以患者为中心的结果的假设。从医疗保健角度进行的成本效益分析将包括增量成本效益比。
该试验将提供有关针对有多种功能障碍或慢性疾病的多患者的本地、协作、阶梯式和个性化护理管理的有效性证据。积极的结果将是朝着实施系统的跨部门慢性护理管理迈出的第一步，以促进现有医疗和护理服务的合理使用，并增强老年人的自我管理能力。
德国临床试验注册处（DRKS）：DRKS00013904；试验注册日期：2018 年 2 月 2 日。
