患有充血性心力衰竭 (CHF)、慢性阻塞性肺病 (COPD) 和痴呆症的患者在专业姑息家庭护理 (SPHC) 中所占比例不足。然而，他们的病情复杂，需要全科医生（GP）和 SPHC 团队之间的合作，及时融入 SPHC，以有效满足他们的需求。以促进联合姑息治疗计划和将晚期慢性非恶性疾病患者及时转移到 SPHC .一项双臂、非盲、整群随机对照试验。德国北部的 49 个全科医生诊所使用基于网络的分组随机化进行了随机化。我们纳入了患有晚期 CHF、COPD 和/或痴呆症的患者。 KOPAL 干预包括 SPHC 护患咨询，以及 SPHC 团队和全科医生之间的跨专业电话病例会议。主要结果是基线后 48 周的入院人数。二次分析检查了对健康相关生活质量和自评健康状况的影响（通过 EuroQol 5D 量表测量）。分析中总共包括 172 名患者。 80.4% 的全科医生诊所之前曾与 SHPC 合作过，其中大多数专门针对癌症患者。基线时，患者报告的平均 EQ-VAS 为 48.4，平均生活质量指数 (EQ-5D-5L) 为 0.63，上一年平均住院次数为 0.80。干预措施并未显着减少入院人数（发生率比 = 0.79，95%CI：[0.49，1.26]，P = 0.31）或住院天数（发生率比 = 0.65，95%CI：[0.28） ，1.49]，P= 0.29）。对生活质量 (Δ = -0.02, 95%CI: [-0.09, 0.05], P = 0.53) 或自评健康 (Δ = -2.48, 95%CI: [-9.95, 4.99]，P = 0.51）。该研究并未显示出对住院治疗和健康相关生活质量的假设影响。未来的研究应侧重于完善这种方法，特别强调优化病例会议的时间安排和实施讨论的治疗计划变更，以改善全科医生和 SPHC 团队之间的合作。© 作者 2024 年。由牛津大学出版社出版代表英国老年医学会。

Patients with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and dementia are underrepresented in specialist palliative home care (SPHC). However, the complexity of their conditions requires collaboration between general practitioners (GPs) and SPHC teams and timely integration into SPHC to effectively meet their needs.To facilitate joint palliative care planning and the timely transfer of patients with advanced chronic non-malignant conditions to SPHC.A two-arm, unblinded, cluster-randomised controlled trial. 49 GP practices in northern Germany were randomised using web-based block randomisation. We included patients with advanced CHF, COPD and/or dementia. The KOPAL intervention consisted of a SPHC nurse-patient consultation followed by an interprofessional telephone case conference between SPHC team and GP. The primary outcome was the number of hospital admissions 48 weeks after baseline. Secondary analyses examined the effects on health-related quality of life and self-rated health status, as measured by the EuroQol 5D scale.A total of 172 patients were included in the analyses. 80.4% of GP practices had worked with SHPC before, most of them exclusively for cancer patients. At baseline, patients reported a mean EQ-VAS of 48.4, a mean quality of life index (EQ-5D-5L) of 0.63 and an average of 0.80 hospital admissions in the previous year. The intervention did not significantly reduce hospital admissions (incidence rate ratio = 0.79, 95%CI: [0.49, 1.26], P = 0.31) or the number of days spent in hospital (incidence rate ratio = 0.65, 95%CI: [0.28, 1.49], P = 0.29). There was also no significant effect on quality of life (∆ = -0.02, 95%CI: [-0.09, 0.05], P = 0.53) or self-rated health (∆ = -2.48, 95%CI: [-9.95, 4.99], P = 0.51).The study did not show the hypothesised effect on hospitalisations and health-related quality of life. Future research should focus on refining this approach, with particular emphasis on optimising the timing of case conferences and implementing discussed changes to treatment plans, to improve collaboration between GPs and SPHC teams.© The Author(s) 2024. Published by Oxford University Press on behalf of the British Geriatrics Society.