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. 2024 Jul 27;14(1):17326.
doi: 10.1038/s41598-024-67624-3.

E-Health-based, trans-sectoral, geriatric health service - Geriatric Network (GerNe)

Michael Mohr  1 , Matthias Büttner  2 , Oliver Deuster  3 , Jochen Heckmann  4 , Frank Huwer  5 , Irene Krämer  6 , Cornelia Lippold  7 , Bettina Siegrist  6 , Susanne Singer  2 , Marina Veith  8 , Ariane Zinke  9 , Roland Hardt  8
Affiliations

E-Health-based, trans-sectoral, geriatric health service - Geriatric Network (GerNe)

Michael Mohr et al. Sci Rep. .

Abstract

Currently, exchange of information between the geriatric clinic and the attending general practitioner (GP) occurs primarily through the doctor's letter after discharging from the clinic. The aim of our study was to reduce readmissions of multimorbid, geriatric patients to the clinic by establishing a new form of care via an electronic case file (ECF) and a consultation service (CS). The discharging geriatric clinic filled out an online ECF. The patient's GP should document quarterly follow-ups in the ECF. The case file was monitored by the discharging clinic due to a consultation service. The primary efficacy endpoint was the rehospitalization rate within one year. The hospitalization rate for patients managed in the project was 83.1/100 person years (PY), while the control group from insurance data had a rate of 69.0/100 PY. The primary endpoint did not show a statistically significant difference (p = 0.15). A total of 195 contacts were documented via CS for 171 participants, mostly initiated by the clinics. The clinical queries primarily concerned drug therapy. The Covid pandemic had an overall impact on hospitalizations. There are many approaches to reducing hospital readmissions after discharge of older patients. Supporting the transition from inpatient to outpatient care by different professional groups or care systems has been shown to have a positive effect. Furthermore, the utilisation of an ECF can also be beneficial in this regard.

Keywords: Case file; Consil; Elderly; Geriatric care; Rehospitalization.

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Conflict of interest statement

The authors declare no competing interests.

Figures

Figure 1
Figure 1
Bidirectional exchange within the framework of the new form of care.
Figure 2
Figure 2
Description of the evaluation design.
Figure 3
Figure 3
Flowchart of patient inclusion of GerNe patients.
See this image and copyright information in PMC

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