Personalized, interdisciplinary patient pathway for cross-sector care of multimorbid patients (eliPfad trial): study protocol for a randomized controlled trial

BackgroundMultimorbid and frail elderly patients often carry a high burden of treatment. Hospitalization due to the onset of an acute illness can disrupt the fragile balance, resulting in further readmissions after hospital discharge. Current models of care in Germany do not meet the needs of this patient group. Rather lack of coordination and integration of care combined with a lack of interdisciplinary approaches result in fragmented and inadequate care and increase the burden of treatment even more.MethodseliPfad is a randomized controlled trial conducted in 6 hospitals in Germany. Multimorbid elderly patients aged 55 or older are randomly assigned to the intervention or control group. Patients in the intervention group receive the eliPfad intervention additional to standard care. The core components of eliPfad are:Early assessment of patients' individual treatment burden and support through a specially trained case managerInvolvement of the patient's general practitioner (GP) right from the beginning of the hospital stayPreparation of an individual, cross-sectoral treatment plan through the interdisciplinary hospital team with the involvement of the patient's GPEstablishment of a cross-sectoral electronic patient record (e-ePA) for documentation and cross-sectoral exchangeSupport/Promote patient adherenceTailored early rehabilitation during the hospital stay, which is continued at homeClose-tele-monitoring of medically meaningful vital parameters through the use of tablets, digital devices, and personal contacts in the home environmentThe intervention period begins in the hospital and continues 6 weeks after discharge. Patients in the control group will be treated according to standard clinical care and discharged according to current discharge management. The primary aim is the prevention/reduction of readmissions in the first 6 months after discharge. In addition, the impact on health-related quality of life, the burden of treatment, survival, self-management, medication prescription, health literacy, patient-centered care, cost-effectiveness, and process evaluation will be examined. Nine hundred forty-eight patients will be randomized 1:1 to intervention and control group.MethodseliPfad is a randomized controlled trial conducted in 6 hospitals in Germany. Multimorbid elderly patients aged 55 or older are randomly assigned to the intervention or control group. Patients in the intervention group receive the eliPfad intervention additional to standard care. The core components of eliPfad are:Early assessment of patients' individual treatment burden and support through a specially trained case managerInvolvement of the patient's general practitioner (GP) right from the beginning of the hospital stayPreparation of an individual, cross-sectoral treatment plan through the interdisciplinary hospital team with the involvement of the patient's GPEstablishment of a cross-sectoral electronic patient record (e-ePA) for documentation and cross-sectoral exchangeSupport/Promote patient adherenceTailored early rehabilitation during the hospital stay, which is continued at homeClose-tele-monitoring of medically meaningful vital parameters through the use of tablets, digital devices, and personal contacts in the home environmentThe intervention period begins in the hospital and continues 6 weeks after discharge. Patients in the control group will be treated according to standard clinical care and discharged according to current discharge management. The primary aim is the prevention/reduction of readmissions in the first 6 months after discharge. In addition, the impact on health-related quality of life, the burden of treatment, survival, self-management, medication prescription, health literacy, patient-centered care, cost-effectiveness, and process evaluation will be examined. Nine hundred forty-eight patients will be randomized 1:1 to intervention and control group.DiscussionIf eliPfad leads to fewer readmissions, proves (cost-)effective, and lowers the treatment burden, it should be introduced as a new standard of care in the German healthcare system.Trial registrationThe trial was registered in the German Clinical Trials Registry (Deutsches Register Klinischer Studien (DRKS)) on 08/14/2023 under the ID DRKS00031500.