AdvantAGE: Implementation and Evaluation of an Interprofessional Tranistional Care Model for Frail Older Adults

Inclusion Criteria

• •Currently admitted to the acute or rehabilitation ward of University Department of Geriatric Medicine
• •Reside in Basel-Stadt
• •Possess the ability to speak and comprehend the German language
• •Scheduled to be discharged to their home
• •65 years or older
• •Identified by a clinician as having a high risk of deterioration due to frailty
• •Additionally, participants must meet at least one of the following criteria:
• •diagnosed with a complex chronic disease requiring support in self-management and disease management, or
• •facing socially challenging situations such as living alone without a supportive network or lacking a GP, or
• •admitted for an acute illness with a brief hospital stay (e.g., infection, cardiac decompensation) and need support in self- and disease management, and continuity of the therapy plan, including close monitoring.