The LEARNING WISDOM Phase II Scale up Project

Summary

Inspired by the Acute Care for Elders program at Mount Sinai Hospital, this study aims to improve care for elderly patients in four hospitals of Chaudière-Appalaches. Focusing on improving transitions between hospital and the community, this project will help professionals to adapt best practices to local context in transition of care for the elderly.

Conditions

• Transition
• Emergencies
• Health Care Utilization
• Frailty

Interventions

BEHAVIORAL

GEM nurse

hospital-based geriatric emergency nurse (GEM nurse) specialist to support patients during the post-discharge transition period

BEHAVIORAL

pre- and post-hospitalization medication list reconciliation

pre- and post-hospitalization medication list reconciliation for elderly

BEHAVIORAL

systematic discharge summaries

systematic discharge summaries given to patients and/or caregiver, and sent to their family physician

BEHAVIORAL

medical follow-up appointment

a planned follow-up appointment with their family physician

BEHAVIORAL

follow-up phone call

a systematic follow-up phone call for discharged patients

OTHER

Wiki-based Knowledge tools

access to wiki-based patient-oriented KT tools

OTHER

Telemonitoring service

access to a community-based telemonitoring service

Sponsors & Collaborators

• Laval University

  lead OTHER

Principal Investigators

• Patrick M Archambault, MD, MSc · Laval University

Study Design

Allocation

NON_RANDOMIZED

Purpose

HEALTH_SERVICES_RESEARCH

Masking

NONE

Model

SEQUENTIAL

Eligibility

Min Age

65 Years

Sex

ALL

Healthy Volunteers

No

Timeline & Regulatory

Start

2019-01-21

Primary Completion

2021-12-31

Completion

2022-12-31

Countries

• Canada

Study Locations