Table 2 Planned delivery of the Continuum of care for frail elderly persons, from the emergency ward to living at home Intervention

Emergency department

A nurse with geriatric expertise makes an assessment of the elderly patients' needs of rehabilitation, nursing, and geriatric care.

For participants who are admitted to the hospital ward, the geriatric assessment is transferred to the ward nurses.

The case manager and the multi-professional team in the community are informed that the patient has visited the emergency care, and whether he/she was transferred to a hospital ward or returned home.

The geriatric assessment is sent to the case manager and the multi-professional team in the municipality.

Hospital ward

The community case manager is responsible for contacting the ward and the elderly person.

The case manager visits participants in the ward, if necessary, contacts the participants' relatives, and initiates support for relatives if necessary.

The case manager continues to have contact with the hospital ward so that discharge planning can start early.

Discharge planning is done in collaboration between the case manager, a qualified social worker, the patient, as well as the nurse and physician in charge at the ward.

Community care

The case manager contacts participants returning home after visiting the emergency department and offers care planning. She also initiates support for patients' relatives if necessary.

The case manager and the multi-professional team make a care plan a couple of days after discharge from the hospital ward. Care planning is done at the older person's own home instead of in the hospital ward, which is the traditional model.

The care plan is based on the results in the geriatric assessment made at the emergency department. Further assessment is made regarding patients' functional abilities, health status, diseases, and ongoing and planned treatment and care. All planning is done in consultation with the patient.

The multi-professional team informs other professionals and care providers, such as home help services and home nursing care, regarding the plan made.

The case manager follows up the care plan within a week, via telephone or home visit, to ensure that everything is working and no new problems have arisen.

The participants are advised that the case manager is available for questions, problem solving, and assistance during office hours.

The case manager has telephone contact with participants once a month except in cases where more frequent contact is needed.

Primary care

Patient's general practitioner is informed by letter that the individual is participating in the research project. Information is given regarding content of the project, i.e., the role of the case manager, and her contact information.

The control group receives traditional care that differs from the intervention in the following aspects:

CONTROL GROUP

No nurse with geriatric expertise available at the emergency department, which implies that no geriatric assessment is made.

No case manager or multi-professional team available, which implies among other things that the community is not informed if an older person has visited emergency department. Nor is the community informed when older people have been hospitalized in a ward if these people do not have community home help services or nursing care. It implies also that the elderly people do not have a one single contact person; instead they contact different care organizations when needed.

For patients being hospitalized, a care plan is made at the hospital ward by the community social worker, community nurse, and rehabilitation staff when necessary.

Follow-up of the care plan is done at patient's home by care providers, i.e., home help providers or home nursing providers.

No follow-up for individuals who don't receive home help or home nursing.