Table 2.
Intervention delivery in interviewed participants
| Patient | Clinical phase | Discharge phase | Post-discharge phase | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| CGA | Geriatric consultation | Geriatric consultation indicated?a | Handover | Number of home visits CNb | First home visit CN within median of 3 days | Medication verification | Evaluation of care plan | Lifestyle discussed | Number of home visits PTc | Joint intake CN/PT | |
| 1 | Yes | No | Yes | Face to face | 4 | No | Yes | No | Yes | 4 | Yes |
| 2 | Yes | No | Yes | Face to face | 4 | Yes | Yes | No | No | 9 | No |
| 3 | Yes | No | Yes | Face to face | 4 | Yes | Yes | No | Yes | 9 | No |
| 4 | Yes | No | Yes | Telephone | 3 | No | Yes | Yes | Yes | 6 | Yes |
| 5 | Yes | No | Yes | Face to face | 5 | No | Yes | Yes | Yes | 7 | No |
| 6 | Yes | No | Yes | Unknown | 4 | Yes | Yes | Yes | Yes | 9 | No |
| 7 | Yes | No | Yes | Telephone | 4 | Yes | Yes | Yes | Yes | 9 | No |
| 8 | Yes | No | Yes | Unknown | 5 | No | Yes | Yes | Yes | 8 | No |
| 9 | Yes | No | No | Face to face | 4 | Yes | Yes | No | Yes | 9 | Yes |
| 10 | Yes | No | No | Telephone | 3 | No | Yes | No | No | 9 | No |
| 11 | Yes | No | No | Face to face | 4 | Yes | Yes | Yes | Yes | 1 | NA |
| 12 | Yes | No | No | Face to face | 4 | Yes | Yes | Yes | No | 0 | NA |
| 13 | Yes | No | No | Face to face | 4 | Yes | Yes | Yes | Yes | 4 | No |
| 14 | Yes | No | No | Telephone | 5 | Yes | Yes | Yes | Yes | 7 | No |
| 15 | Yes | Yes | Yes | Face to face | 5 | Yes | Yes | No | Yes | 7 | No |
| 16 | Yes | No | Yes | Face to face | 3 | Yes | Yes | No | Yes | 2 | No |
Abbreviations: CGA comprehensive geriatric assessment, CN community nurse, NA not applicable, PT physical therapist
a Geriatric team consultation was indicated in case of ≥5 geriatric problems of which ≥1 problem had to be within the psychological domain. b Four home visits, according to the intervention protocol. An extra home visit was performed on indication, assessed by the CN. c Max. nine home-based rehabilitation session, according to the intervention protocol