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PROJECT DESCRIPTION

Programs will be implemented in hospitals where old frail patients are attended, with well-established Geriatric facilities, able to offer a skilled management of medical and surgical patients(including established coordination with Primary and Social Care).

Geriatric teams will access the target patients to detect frailty and to provide the best-fitted management,using classical techniques and instruments of Comprehensive Geriatric Assessment. Demographic, functional, and clinical basal conditions will be collected. Those ones meeting Fried´s criteria will be identified as frail.

An intervention program will be implemented after randomisation: a comprehensive management plan of the patients,covering both in-hospital and postdischarge time, agreed with the treating physician(s)/surgeon.This management will consist of the therapeutic plan, access to geriatric levels of care, coordination with Primary and Social care, rehabilitation, and discharge plan. Patient follow-up will be the done by the geriatric team, the treating physician/surgeon and Primary and Social care, as required.

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Expected outcomes

Data on functional status, episodes of hospitalization, mean stay, treatments for the main disease(s), surgical procedures and complications of main interest will be timely collected. In the long-term we will collect data on death, permanent institutionalization, and associated economic costs. Any contingency that could impede the implementation or progress of the program will be collected to assess its feasibility.

The main expected outcomes will be: Decreased rates of hospitalization and re-hospitalization, stays at Emergency Rooms and episodes of delirium and nosocomial infection, reduced mean stay, post-surgical complications as a whole and by surgical procedure, and number of inappropriate drugs, increasing adherence. In relation to functional outcomes, we will reduce the rate of functional deterioration and permanent institutionalization, and increase the number of patients attending Primary Care on a home-based strategy. All these changes will decrease the associated costs of care.

If succesful, it should change the way in which we deliver the care for older frail patients.

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Workplan: Work Packages definition

The workplan has been divided in 3 Horizontal Work Packages and 4 Core Work Packages, described below:

WP1: Coordination of the project: Actions undertaken to manage the project and to make sure that it is implemented as planned

WP2: Dissemination of the project: Actions undertaken to ensure that the results and deliverables of the project will be made available to the target groups

WP3: Evaluation of the project: Actions undertaken to verify if the project is being implemented as planned and reaches the objectives

WP4: Preliminary Groundwork: This WP will develop three main tasks: 1) the design of the final protocols and questionnaire to detect, intervene, monitor intervention and record the data in the different levels of care, 2) Pilot studies of both phases of the project: detection-feasibility and intervention 3) Ethical issues

WP5: Detection of frail patients:This WP will manage the strategies to detect frail patients in the different settings, the determination of the sample size, the time to include patients and the procedures involved. It will also be the responsible for the study relating to feasibility of detection.

WP6: Intervention on frail patients: This WP will manage the implementation of the intervention (the core one and other specific interventions), the final sample size, the follow-up of the patients (mean, 1 year), and the time of re-assessment. It will be also the responsible for the study about feasibility of the intervention(s)

WP7: Data analysis and management: This WP manage the case record forms and the central database and analyse the data collected during the project in accordance with the agreed Statistical Analysis Plan, in order to ensure that it is complete and accurate and to undertake the statistical analysis in a timely and efficient manner.

 

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This website arises from the project “FRAILCLINIC, Feasibility and effectiveness of the implementation of programs to screen and manage frail older patients in different clinical settings”, which has received funding from the European Union, in the framework of the Health Programme (2008-2013).

CONTACT

Dr. Leocadio Rodríguez Mañas

Jefe de Servicio de Geriatría

Hospital Universitario de Getafe

Ctra. de Toledo, Km. 12,5

28905-Getafe

Spain

Phone: +34 916 839 360 (ext. 6412)

FAX: +34 916 839 210

e-mail: leocadio.rodriguez@salud.madrid.org
Twitter: https://twitter.com/Frailclinic

The content of this website represents the views of the author and it is his sole responsibility; it can in no way be taken to reflect the views of the European Commission and / or the Executive Agency for Health and Consumers or any other body of the European Union. The European Commission and / or the Executive Agency do(es) not accept responsibility for any use that may be made of the information it contains.

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