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We do include caregivers in the study and access patient records to achieve the best possible valid information. Furthermore, we will include cognitive status as a mediating factor in our analyses. The relevance of this study for old and very old people is high.

Intersec-CM addresses: a relevant problems in the health-care system sectorization of in-hospital and primary care and b inadequate treatment and care for acutely ill patients with cognitive impairment in the transition between hospital and primary care as a highly prevalent target group. It makes use of evidence-based methods with relevant outcomes for elderly patients quality of life and ADL and relevant outcomes to the overall health of the target group.

We expect that the trial will add scientific evidence to improve the treatment and care of PCI at the interface between hospital and primary care. We assume that the adapted dementia care management will improve patient-oriented outcomes as well as system-relevant outcomes.

In the event of proving efficacy, this trial will deliver a proof of concept for implementation into routine care and—ideally—will improve the current health-care system. The results expected from this trial could facilitate the implementation of intersectoral care management systematically on a larger scale. Cost-effectiveness analyses as well as an independent mixed-methods process evaluation which will be described in more detail elsewhere increase the likelihood of meeting these goals.

Scientifically, the trial allows an in-depth analysis of mediating and moderating effects for different health outcomes at the interface between hospital and primary care.

We expect frailty to be a risk factor for worse health outcomes over time. Additionally, we will add to the knowledge base of the trajectory of cognitive status and delirium from hospital stays to primary care.

Identifying risk factors will help to improve treatment and care by allowing these to be targeted in future interventions or by making changes to the system. By highlighting treatment and care, our study will provide insights into unmet needs at the time of hospital admission, and the opportunities and barriers to meeting those needs during the hospital stay or shortly after. There will be descriptive analyses of common needs that emerge directly after discharge and an estimate of which of these needs can be met immediately.

Recommendations for how intersectoral care management can be implemented in the current systems will be developed and promoted. Informal caregivers will be actively involved in all phases of the study. It is now common knowledge that they play an important role in dementia care. Our trial will provide descriptive details of which informal caregivers are involved, at what times, to what extent, and how. We will add descriptive knowledge about the informal caregivers, their social situation, their own unmet needs, whether they may benefit from the intervention, and if yes, how exactly.

This knowledge may influence how informal caregivers are systematically involved and supported in treatment and care at the interface between hospital and primary care and sustainably thereafter. Ultimately, the results will not be limited to PCI but will extend to elderly people transitioning between in-hospital and primary care in general Additional file 1.

Original Format

The trial is currently recruiting. The first participant was enrolled on 1 November By 22 July , participants had been enrolled. The expected end of recruitment is 31 October The current protocol is version 1. Bern: Huber Verlag; Schwartz FW. Das Gesundheitswesen. Bedarfsgerechtigkeit und Wirtschaftlichkeit Gutachten.

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Health Economics Review, Springer | IDEAS/RePEc

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