Intervention components
disease deterioration
Overall, the hospital-based intervention consisted of three components covering the pre-discharge and post-discharge phases.Pre-discharge phase: discharge transportation and home visitOn the day of discharge, patients were physically escorted home from the hospital by a project worker, either in a project car or by bedridden-patient transportation, if they were physically or mentally incapable of sitting in a car. Whichever means of transportation, a physical home visit was conducted immediately after the patient’s return home or on the first weekday afterwards. During the visit, the project worker ensured that the patient felt as safe as possible, basic human needs were met, a medication reconciliation was conducted, the patient’s nutritional status was assessed, fall prevention efforts were initiated and challenges and concerns were discussed and resolved whenever possible. A video conference for the following working day was arranged during the visit.Post-discharge phase: cross-sectional video conference and telephone consultationsA video conference was conducted on the following working day. The conference aim was to bridge the gap between hospital and primary healthcare professionals by ensuring (1) a smooth transition with timely and sufficient communication; (2) that questions, barriers and worries were handled; and (3) continuity of care and treatment plans were arranged. The project worker participated from the hospital, while the patient, district nurse and relatives participated from the patient’s home. If a video conference was not possible, a telephone conference was held instead. To facilitate the conference, one computer or tablet was provided for the project worker, and one was provided for the district nurses in each of the three participating municipalities.Telephone consultations with the project workers or geriatricians were offered for up to seven days after discharge. Patients, relatives, district nurses and GPs were given a direct phone number that was answered by either a project worker or a nurse coordinator 24/7. Among other things, questions about hospital-based treatment and care, modifications of the treatment and care plans and disease deterioration could be discussed during these consultations.