The Effects of a Health-social Partnership Program for Discharged Non-frail Older Adults

Study Results

Results pending

The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.

Basic Information

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Recruitment Status

COMPLETED

Clinical Phase

NA

Total Enrollment

75 participants

Study Classification

INTERVENTIONAL

Study Start Date

2017-06-19

Study Completion Date

2020-04-30

Brief Summary

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Previous studies supporting discharged patients are hospital-based which admission criteria tend to include mainly those with complex needs and/or specific disease conditions. This study captured the service gap where these non-frail older patients might have no specific medical problem upon discharge but they might encounter residual health and social issues when returning home.

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Detailed Description

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Objective: To compare the effect of a community-based health-social partnership program with usual care for discharged community-dwelling non-frail older adults on their health-related quality of life, activities of daily living, depressive symptoms, and use of health services.

Design: A randomized controlled trial. Participants: Discharged community-dwelling non-frail older adults from an emergency medical ward in an intervention (n=37) and a control (n=38) group.

Interventions: Discharged older adults were randomized to receive usual care or complex interventions, including structured assessment, health education, goal empowerment, and care coordination supported by a health-social team.

Main measures: The outcomes were measured at pre-intervention (T1) and at three months post-intervention (T2) using the Medical Outcomes Study 12-item Short Form, the Modified Barthel Index and the Geriatric Depression Scale.

Conditions

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Transition Partner Communication

Study Design

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Allocation Method

RANDOMIZED

Intervention Model

PARALLEL

Primary Study Purpose

PREVENTION

Blinding Strategy

SINGLE

Outcome Assessors

Study Groups

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Intervention group

The subjects in this group receive complex interventions, including structured assessment, health education, goal empowerment, and care coordination supported by a health-social team.

Group Type EXPERIMENTAL

Complex interventions

Intervention Type OTHER

An advanced practice nurse (APN) from a hospital discharge team visited them to familiarize him/herself with their condition and prepare a discharge plan. A face-to-face or telephone call handover between the APN and the project nurse case manager (NCM) was performed before the client was discharged. The past and current medical conditions, medical and nursing management, and follow-up appointments were discussed. After discharge home, the NCM, functioning as the leader of health-social care team, conducted the initial assessment in the first home visit to identify the client's health and social problems within one week of discharge. Community workers, supervised by both the nurse case manager and social worker, provided telephone follow-up and subsequent home visits to monitor the client's progress and provide support when necessary.

Control group

The control group received usual discharge care and community resources that were made available to them as appropriate. A monthly social call was made to each client in the control group in order to exclude social effects. The contents of the social call, such as asking about entertainment and clients' hobbies, were set in the protocol.

Group Type OTHER

Usual care

Intervention Type OTHER

Social call was given to this group.

Interventions

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Complex interventions

An advanced practice nurse (APN) from a hospital discharge team visited them to familiarize him/herself with their condition and prepare a discharge plan. A face-to-face or telephone call handover between the APN and the project nurse case manager (NCM) was performed before the client was discharged. The past and current medical conditions, medical and nursing management, and follow-up appointments were discussed. After discharge home, the NCM, functioning as the leader of health-social care team, conducted the initial assessment in the first home visit to identify the client's health and social problems within one week of discharge. Community workers, supervised by both the nurse case manager and social worker, provided telephone follow-up and subsequent home visits to monitor the client's progress and provide support when necessary.

Intervention Type OTHER

Usual care

Social call was given to this group.

Intervention Type OTHER

Eligibility Criteria

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Inclusion Criteria

* resided in the service areas of the study hospital,
* were aged 60 or over,
* were cognitively competent with a score greater than 26 in the Montreal Cognitive Assessment Hong Kong version,
* were living at home before and after discharge from the hospital,
* had scores of \<5 on the Clinical Frailty Scale (Note: a patient is considered to be non-frail if they have a score less than 5), and
* were fit for medical discharge

Exclusion Criteria

* were not able to communicate,
* could not be reached by phone,
* were bed-bound,
* had active psychiatric problems,
* were already engaged in other structured health or social programs, and
* would not be staying in Hong Kong for the three months of the study

Minimum Eligible Age

60 Years

Eligible Sex

ALL

Accepts Healthy Volunteers

Yes