Table 2 Implementation fidelity for each intervention component and moderating factors affecting fidelity
Intervention component | The intervention component | Extent to which these were conducted | Moderating factor affecting fidelity |
|---|---|---|---|
1 | At the ED, a nurse with geriatric expertise makes an assessment of the patients' needs of rehabilitation, nursing, and care. | Seldom (made at wards not at the ED) | Recruitment |
2 | The geriatric assessment is transferred to the hospital ward for participants who are admitted to a ward. | Seldom (since assessment was made at the wards) | Recruitment |
3 | The nurse with geriatric expertise informs the community team that the patient has visited the ED, and whether he/she was transferred to a ward or returned home. | Always | |
4 | The geriatric assessment is sent to the CM and the multi-professional team in the municipality. | Always | |
For participants who are admitted to the hospital ward: | |||
5 | CM visits participants in the ward. | Always | |
6 | CM contacts a patient responsible nurse at the ward to get information about the estimated time at the ward. | Always | |
For participants discharged from the ward: | |||
7 | A patient responsible nurse at the ward contacts the CM before discharge. | Always | |
8 | Discharge plan is done in collaboration between CM, a qualified social worker, the patient, a nurse and physician at the ward. | Always | |
Participants coming home from ED or from a ward: | |||
9 | CM contacts participants and offers care planning. | Always | |
10 | CM initiates support for patients' relatives if necessary. | Always, when a participant has a relative and allows the contact, which is 10% of the participants | Participant responsiveness |
11 | CM and the multi-professional team make a care plan at the elderly person's home a couple of days after the discharge. | Always at home, 10% of planning not all team members participating | Context: resources for employment |
12 | The care plan is based on the results in the geriatric assessment. | Always | |
13 | All planning is done in consultation with the patient. | Always | |
14 | The team informs other care providers regarding the plan made. | Always | |
15 | CM follows up the care plan within a week (telephone or home visit). | Always, via telephone | |
16 | CM has telephone contact with participants once a month except in cases where more frequent contact is needed. | Always, if the participant wants this. 5% wanted to take the contact by themselves. | Participant responsiveness |
17 | The participants are advised that CM is available for problem solving and assistance during office hours. | Always | |
18 | Patient's GP is informed by letter that the individual is participating in the project. | Always | |