%0 Journal Article
%@ 1472-6963
%A Forstner, Johanna
%A Straßner, Cornelia
%A Kunz, Aline
%A Uhlmann, Lorenz
%A Freund, Tobias
%A Peters-Klimm, Frank
%A Wensing, Michel
%A Kümmel, Stephanie
%A El-Kurd, Nadja
%A Rück, Ronja
%A Handlos, Bärbel
%A Szecsenyi, Joachim
%C London
%D 2019
%F heidok:26244
%I BioMed Central
%J BMC Health Services Research
%K Patient admission, Patient discharge, Cross-sectoral care, Continuity of patient care, Patient readmission, Communication, Interprofessional coordination, Patient-centered care, Health services research, Implementation science
%N 206
%P 1-10
%T Improving continuity of patient care across sectors: study protocol of a quasi-experimental multi-centre study regarding an admission and discharge model in Germany (VESPEERA)
%U https://archiv.ub.uni-heidelberg.de/volltextserver/26244/
%V 19
%X Background: Hospitalisations are a critical event in the care process. Insufficient communication and uncoordinated follow-up care often impede the recovery process of the patient resulting in a high number of rehospitalisations and increased health care costs. The overall aim of this study is the development, implementation and evaluation of a structured programme (VESPEERA) to improve the admission and discharge process.    Methods: We will conduct an open quasi-experimental multi-centre study with four intervention arms. A cohort selected from insurance claims data will serve as a control group reflecting usual care. The intervention will be implemented in 25 hospital departments and 115 general practices in 9 districts in Baden-Wurttemberg. Eligibility criteria for patients are: age > 18 years, hospital admission or hospitalisation, insurance at the sickness fund “AOK Baden-Wurttemberg”, enrolment in general practice-centred care contract. Each study arm will receive different intervention components based on the point of study enrolment and the patient’s medical need. The interventions comprise a) a structured assessment in the general practice prior to admission resulting in an admission letter b) a discharge conversation by phone between hospital and general practice, c) a structured assessment and care plan post-discharge and d) telephone monitoring for patients with a high risk of rehospitalisation. The assessments are supported by a software tool (“CareCockpit”), originally developed for structured case management programmes. The primary outcome (rehospitalisation due to the same indication within 90 days) and a range of secondary outcomes (rehospitalisation due to the same indication within 30 days; hospitalisations due to ambulatory care-sensitive conditions; delayed prescription of medication and medical products/ devices and referral to other health practitioner/s after discharge; utilisation of emergency or rescue services within 3 months; average care cost per year and patient participating in the VESPEERA programme) and quality indicators will be determined based on insurance claims data and CareCockpit data. Additionally, a patient survey on satisfaction with cross-sectoral care and health related quality of life will be conducted.    Discussion: Based on the results, area-wide implementation in usual care is well sought. This study will contribute to an improvement of cross-sectoral care during the admission and discharge process.    Trial registration:  DRKS00014294  on DRKS / Universal Trial Number (UTN): U1111–1210-9657, Date of registration 12/06/2018.