Improving continuity of patient care across sectors: study protocol of a quasi-experimental multi-centre study regarding an admission and discharge model in Germany (VESPEERA)

BMC Health Serv Res. 2019 Mar 29;19(1):206. doi: 10.1186/s12913-019-4022-4.


Background: Hospitalisations are a critical event in the care process. Insufficient communication and uncoordinated follow-up care often impede the recovery process of the patient resulting in a high number of rehospitalisations and increased health care costs. The overall aim of this study is the development, implementation and evaluation of a structured programme (VESPEERA) to improve the admission and discharge process.

Methods: We will conduct an open quasi-experimental multi-centre study with four intervention arms. A cohort selected from insurance claims data will serve as a control group reflecting usual care. The intervention will be implemented in 25 hospital departments and 115 general practices in 9 districts in Baden-Wurttemberg. Eligibility criteria for patients are: age > 18 years, hospital admission or hospitalisation, insurance at the sickness fund "AOK Baden-Wurttemberg", enrolment in general practice-centred care contract. Each study arm will receive different intervention components based on the point of study enrolment and the patient's medical need. The interventions comprise a) a structured assessment in the general practice prior to admission resulting in an admission letter b) a discharge conversation by phone between hospital and general practice, c) a structured assessment and care plan post-discharge and d) telephone monitoring for patients with a high risk of rehospitalisation. The assessments are supported by a software tool ("CareCockpit"), originally developed for structured case management programmes. The primary outcome (rehospitalisation due to the same indication within 90 days) and a range of secondary outcomes (rehospitalisation due to the same indication within 30 days; hospitalisations due to ambulatory care-sensitive conditions; delayed prescription of medication and medical products/ devices and referral to other health practitioner/s after discharge; utilisation of emergency or rescue services within 3 months; average care cost per year and patient participating in the VESPEERA programme) and quality indicators will be determined based on insurance claims data and CareCockpit data. Additionally, a patient survey on satisfaction with cross-sectoral care and health related quality of life will be conducted.

Discussion: Based on the results, area-wide implementation in usual care is well sought. This study will contribute to an improvement of cross-sectoral care during the admission and discharge process.

Trial registration: DRKS00014294 on DRKS / Universal Trial Number (UTN): U1111-1210-9657, Date of registration 12/06/2018.

Keywords: Communication; Continuity of patient care; Cross-sectoral care; Health services research; Implementation science; Interprofessional coordination; Patient admission; Patient discharge; Patient readmission; Patient-centered care.

Publication types

  • Multicenter Study

MeSH terms

  • Adult
  • Continuity of Patient Care / organization & administration*
  • Delivery of Health Care / organization & administration*
  • Female
  • Germany
  • Hospitalization / statistics & numerical data*
  • Humans
  • Male
  • Middle Aged
  • Patient Discharge*
  • Prospective Studies
  • Quality Improvement / organization & administration*