gms | German Medical Science

Introduction and Background: The German health care system is separated in 3 care sectors; 1. primary care and treatment (family doctor), 2. secondary treatment in hospital and 3. rehabilitation. This separation often causes an inefficient, uncoordinated treatment [1]. Especially for elderly patients with cognitive impairments this may lead to considerable problems. At the transition from the hospital to primary care, the coordination of (postoperative) care and the timely communication between the health care provider is often insufficient. Consequences include a worsening of the disease and comorbidities, higher rates of re-entry to the hospital and ultimately end in higher costs for the individual institutions. Models of collaborative care have shown their effectiveness in primary care [2]. The “Intersec-CM”-Study evaluats a structured support algorithm for elderly people with cognitive impairments during and after hospital stays in the (inter-) sectoral German health care system.

Research Questions: In my current Ph.D.-Thesis I would like to investigate to what extent the quality of life of cognitively impaired persons, their socio-economic environment and their care providers benefit from cross-sectoral care management at the interface of inpatient and outpatient care?

Intervention: In our study we use a specialized Intervention-Management-Software (IMS), wich was developed for this purpose in collaboration with the Institute of Community Medicine in Greifswald. With that innovated instrument trained study nurses, so called Dementia Care Managers (DCM), idendity and adress unmet needs of patients. In close collaboration with the hospital, the family doctor and other care providers, the DCM and IMS recommendations for intervention are integrated into a patient's individual treatment plan. The DCM monitors and supports patients in the implementation of the developed intervention plan.

Methods: It´s a long-term multisite randomized controlled trial (intervention vs. care as usual) with data collected during hospital admission (T1), 3 months (T2), and 12 months after release (T3) and finishes with a 360°-Process evaluation.

Expected results: The primary expected result in our study is (1) a higher quality of life compared to a control group, (2) degree of social inclusion. The secondary results are an adequate treatment and nursing care of people with cognitive impairments and their families, the reduction of hospital re-entry and delay of institutionalization.

Benefit: Transfer of a holistic dementia care concept into the cross-sectoral supply of care.