Evid Based Nurs 3:83 doi:10.1136/ebn.3.3.83
  • Treatment

Comprehensive, in-hospital geriatric assessment plus an interdisciplinary home intervention after discharge reduced length of subsequent readmissions and improved functioning

 QUESTION: Is an in-hospital, comprehensive geriatric assessment alone or combined with an interdisciplinary home intervention after discharge more effective than usual care?


Randomised, {allocation concealed}*, unblinded, controlled trial with follow up at 1 year.


A university affiliated geriatric hospital in Heidelberg, Germany and patient homes.


545 patients (mean age 81 y, 73% women) who were admitted from home with acute illness and had multiple chronic conditions or functional deterioration after convalescence, or were at risk of nursing home placement. Patients with terminal illness or severe dementia were excluded. Follow up at 1 year was 94%.


181 patients were allocated to comprehensive, geriatric assessment plus in-hospital and post-discharge treatment at home by an interdisciplinary team, which consisted of 3 nurses, a physiotherapist, an occupational therapist, and a social worker (home intervention group). The in-hospital, comprehensive assessment addressed activities of daily living, cognition, social situation, and perceived health. The team provided additional treatment while the patient was …

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