Table 2

Implementation fidelity for each intervention component and moderating factors affecting fidelity

Intervention component

The intervention component

Extent to which these were conducted

Moderating factor affecting fidelity

1

At the ED, a nurse with geriatric expertise makes an assessment of the patients' needs of rehabilitation, nursing, and care.

Seldom (made at wards not at the ED)

Recruitment

2

The geriatric assessment is transferred to the hospital ward for participants who are admitted to a ward.

Seldom (since assessment was made at the wards)

Recruitment

3

The nurse with geriatric expertise informs the community team that the patient has visited the ED, and whether he/she was transferred to a ward or returned home.

Always

4

The geriatric assessment is sent to the CM and the multi-professional team in the municipality.

Always

For participants who are admitted to the hospital ward:

5

CM visits participants in the ward.

Always

6

CM contacts a patient responsible nurse at the ward to get information about the estimated time at the ward.

Always

For participants discharged from the ward:

7

A patient responsible nurse at the ward contacts the CM before discharge.

Always

8

Discharge plan is done in collaboration between CM, a qualified social worker, the patient, a nurse and physician at the ward.

Always

Participants coming home from ED or from a ward:

9

CM contacts participants and offers care planning.

Always

10

CM initiates support for patients' relatives if necessary.

Always, when a participant has a relative and allows the contact, which is 10% of the participants

Participant responsiveness

11

CM and the multi-professional team make a care plan at the elderly person's home a couple of days after the discharge.

Always at home, 10% of planning not all team members participating

Context: resources for employment

12

The care plan is based on the results in the geriatric assessment.

Always

13

All planning is done in consultation with the patient.

Always

14

The team informs other care providers regarding the plan made.

Always

15

CM follows up the care plan within a week (telephone or home visit).

Always, via telephone

16

CM has telephone contact with participants once a month except in cases where more frequent contact is needed.

Always, if the participant wants this. 5% wanted to take the contact by themselves.

Participant responsiveness

17

The participants are advised that CM is available for problem solving and assistance during office hours.

Always

18

Patient's GP is informed by letter that the individual is participating in the project.

Always

ED emergency department, CM case manager, GP general practitioner

Hasson et al. Implementation Science 2012 7:23   doi:10.1186/1748-5908-7-23