The aim of RubiN is to implement a care and case management system that supports geriatric patients to enable them to remain in their own homes for as long as possible.

The demographic change is accompanied by a growing number of chronically and multimorbidly ill patients. Especially among geriatric patients, acute and chronic (multiple) illnesses occur simultaneously. The term geriatrics therefore does not refer to the entirety of elderly people, but describes a condition associated with advanced age. This is compounded by age-related physiological changes, as a result of which the residual capacities of various bodily functions are increasingly limited and everyday activities can no longer be managed sufficiently. In addition, the fragmented structures and scarcely networked sectors of the German healthcare system are not designed for the care of elderly, chronically or multimorbidly ill patients.

Therefore, the project “RubiN – Regional uninterrupted care in a Network” aims to improve the identification, care setting and health status of geriatric patients; in particular, the independence of elderly patients is to be preserved. For this purpose, within accredited practice networks, a multiprofessional, cross-sectoral and assessment-based training curriculum for health professionals is to be used for the case management of geriatric patients. At the same time, the workload of primary care physicians in geriatric patient care should be reduced. To achieve this, legally secure delegation in care networks must be ensured by developing and introducing a set of general structural and process requirements.


The evaluation of the project is based on three levels: First, a quantitative evaluation with primary data is conducted. The data is collected using standardized measurement instruments. The primary patient-related endpoint is the ability to cope with everyday activities after twelve months, based on the Barthel Index. Furthermore, a formative process evaluation is carried out, in which the aspects of acceptance, feasibility and implementation of the intervention are examined. This will involve the use of both qualitative and quantitative survey methods. A health economic evaluation will also be conducted. The design of the evaluation is prospectively controlled.