A Model for Continuous Care of Fragile Patients

NCT ID: NCT07299344

Last Updated: 2025-12-23

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

NOT_YET_RECRUITING

Total Enrollment

100 participants

Study Classification

OBSERVATIONAL

Study Start Date

2025-12-31

Study Completion Date

2028-06-30

Brief Summary

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This observational study aims to monitor functional status and identify potential declines in the functioning of medically fragile patients with neurological and/or orthopedic conditions, representing an added value for ensuring appropriate patient management. This approach improves system efficiency and supports a proactive strategy that promotes the appropriate use of resources.

Detailed Description

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This is a prospective, observational, non-profit study.

Primary Objective:

To compare functional and cognitive test results at discharge from "La Residenza" rehabilitation center (Rodello - CN- Italy) with remote assessments at patients' homes, demonstrating that Timed Up and Go (TUG) and GPCog tests, validated in-person, can be reliably administered via telemedicine.

Secondary Objectives:

To monitor motor and cognitive function remotely at 3, 6, and 12 months after discharge, assessing clinical course and disease progression, and evaluating patient condition as stable, improved, or deteriorated.

Study Timeline and Sample Size:

Recruitment is expected from September 2025 to March 2026, with last follow-up in March 2027 and an additional 6 months for data analysis and publication. A total of 100 patients (50 orthopedic, 50 neurological) will be enrolled, accounting for a 25% expected loss, based on power calculations for paired t-tests comparing in-person and remote assessments.

Conditions

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Neurological Disorders Orthopedic Disorders Functional Decline Fragile and More Vulnerable

Keywords

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Functional Monitoring Functional Decline Medically Fragile Patients Neurological Disorders Orthopedic Conditions Rehabilitation Proactive Care Model Continuous Patient Management Rehabilitation Setting Early Detection of Functional Changes telemedicine

Study Design

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Observational Model Type

COHORT

Study Time Perspective

PROSPECTIVE

Study Groups

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Medically Fragile Patients with Neurological or Orthopedic Conditions

This cohort includes medically fragile adult patients with mild-to-moderate neurological or orthopedic conditions who are able to ambulate independently with or without assistive devices. Eligible neurological conditions include mild-to-moderate stroke (mRS ≤ 3), Multiple Sclerosis (EDSS ≤ 6.5), Parkinson's disease or parkinsonisms, and neuromuscular diseases. Eligible orthopedic conditions include femur, pelvis, or humerus fractures. Participants must have adequate cognitive function (MMSE ≥ 24) and the presence of a cognitively capable caregiver.

Telemedicine-Based Functional Monitoring

Intervention Type OTHER

This intervention provides structured functional monitoring of medically fragile patients with neurological and/or orthopedic conditions using telemedicine. Patients undergo MMSE, Rankin Scale, Barthel Index, TUG, GPCog, and SF-36 assessments at discharge and during follow-up at 3, 6, and 12 months. Patient and caregiver satisfaction with remote monitoring is also evaluated. All remote assessments are performed via the TESI eViSus BioCare® system on mobile devices, allowing early detection of functional decline and supporting proactive patient management.

Interventions

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Telemedicine-Based Functional Monitoring

This intervention provides structured functional monitoring of medically fragile patients with neurological and/or orthopedic conditions using telemedicine. Patients undergo MMSE, Rankin Scale, Barthel Index, TUG, GPCog, and SF-36 assessments at discharge and during follow-up at 3, 6, and 12 months. Patient and caregiver satisfaction with remote monitoring is also evaluated. All remote assessments are performed via the TESI eViSus BioCare® system on mobile devices, allowing early detection of functional decline and supporting proactive patient management.

Intervention Type OTHER

Other Intervention Names

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Remote Functional Assessment Protocol Telemedicine Follow-Up Monitoring

Eligibility Criteria

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Inclusion Criteria

* Adult medically fragile patients with one of the following neurological conditions: mild-to-moderate stroke (Rankin ≤ 3), Multiple Sclerosis (EDSS ≤ 6.5), Parkinson's disease or parkinsonisms, neuromuscular diseases; or orthopedic conditions: femur, pelvis, or humerus fracture.
* Able to walk independently, with or without assistive devices.
* Adequate cognitive function (MMSE ≥ 24).
* Patient or caregiver owns and can use a mobile device with internet/data connection.
* Presence of a cognitively capable, cooperative caregiver willing to participate in the study.

Exclusion Criteria

* Patients with severe neurological or orthopedic conditions who cannot walk independently, even with assistive devices.
* Patients with moderate or severe cognitive impairment (MMSE \< 24).
* Patients with Barthel Index \> 60.
* Patients or caregivers unable to use a mobile device or without internet/data connection.
* Patients without a cooperative, cognitively capable caregiver.
Minimum Eligible Age

18 Years

Eligible Sex

ALL

Accepts Healthy Volunteers

No

Sponsors

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Casa di Cura La Residenza di Rodello (CN, Italy)

UNKNOWN

Sponsor Role collaborator

Azienda Sanitaria Locale CN2 Alba-Bra

OTHER

Sponsor Role lead

Responsible Party

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Responsibility Role SPONSOR

Locations

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Azienda Sanitaria Locale CN2 Alba-Bra, Ospedale Michele e Pietro Ferrero

Verduno, CN, Italy

Site Status

Countries

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Italy

Central Contacts

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Michele Dotta, Dr.

Role: CONTACT

Phone: +39.0172.1408670

Email: [email protected]

References

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Feeney J, Savva GM, O'Regan C, King-Kallimanis B, Cronin H, Kenny RA. Measurement Error, Reliability, and Minimum Detectable Change in the Mini-Mental State Examination, Montreal Cognitive Assessment, and Color Trails Test among Community Living Middle-Aged and Older Adults. J Alzheimers Dis. 2016 May 31;53(3):1107-14. doi: 10.3233/JAD-160248.

Reference Type BACKGROUND
PMID: 27258421 (View on PubMed)

Giavarina D. Understanding Bland Altman analysis. Biochem Med (Zagreb). 2015 Jun 5;25(2):141-51. doi: 10.11613/BM.2015.015. eCollection 2015.

Reference Type BACKGROUND
PMID: 26110027 (View on PubMed)

Viglino G, Neri L, Barbieri S, Tortone C. Peritoneal dialysis training performed remotely: results and comparison with Home Training. Clin Exp Nephrol. 2023 Jan;27(1):72-78. doi: 10.1007/s10157-022-02276-z. Epub 2022 Sep 21.

Reference Type BACKGROUND
PMID: 36129554 (View on PubMed)

Brodaty H, Pond D, Kemp NM, Luscombe G, Harding L, Berman K, Huppert FA. The GPCOG: a new screening test for dementia designed for general practice. J Am Geriatr Soc. 2002 Mar;50(3):530-4. doi: 10.1046/j.1532-5415.2002.50122.x.

Reference Type BACKGROUND
PMID: 11943052 (View on PubMed)

van Dyck CH, Swanson CJ, Aisen P, Bateman RJ, Chen C, Gee M, Kanekiyo M, Li D, Reyderman L, Cohen S, Froelich L, Katayama S, Sabbagh M, Vellas B, Watson D, Dhadda S, Irizarry M, Kramer LD, Iwatsubo T. Lecanemab in Early Alzheimer's Disease. N Engl J Med. 2023 Jan 5;388(1):9-21. doi: 10.1056/NEJMoa2212948. Epub 2022 Nov 29.

Reference Type BACKGROUND
PMID: 36449413 (View on PubMed)

de Joode SGCJ, Kalmet PHS, Fiddelers AAA, Poeze M, Blokhuis TJ. Long-term functional outcome after a low-energy hip fracture in elderly patients. J Orthop Traumatol. 2019 Apr 11;20(1):20. doi: 10.1186/s10195-019-0529-z.

Reference Type BACKGROUND
PMID: 30976999 (View on PubMed)

Other Identifiers

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AFTER

Identifier Type: -

Identifier Source: org_study_id