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

NCT04434742 | Completed

• 1 other identifier: HSP002
• Study Type: interventional
• Target: 75
• Locations: 1 country
• Sites: 1

Brief Summary

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.

Conditions

Transition; Partner Communication

Outcome Measures

Primary Outcomes (1)

• Change from baseline Health-related quality of life: SF-12 at 3 months

  The goal for this program was to enable older adults to live with optimum quality of life in their own environment through receiving support from the collaboration of nurse case managers and social workers. Quality of life was measured by SF-12, which has been shown to be useful in Chinese elderly patients. The questionnaire has 12 items organized into eight categories (physical functioning, role limitation due to emotional and physical problems, mental health scale, general health, bodily pain, social functioning, and vitality), and has been validated in numerous studies.

  At baseline pre-intervention and at three months when the interventions were completed.

Secondary Outcomes (3)

• Change from baseline Activity of daily living at 3 months

  At baseline pre-intervention and at three months when the interventions were completed.

• Change from baseline Presence of depressive symptoms at 3 months

  At baseline pre-intervention and at three months when the interventions were completed.

• Change from Total number of unplanned outpatient department, general practitioner, and emergency department visits, hospital admissions and total number of health service attendances at 3 months

  At baseline pre-intervention and at three months when the interventions were completed.

Study Arms (2)

Intervention group

EXPERIMENTAL

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

Other: Complex interventions

Control group

OTHER

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.

Other: Usual care

Interventions

Complex interventions 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.

Intervention group

Usual care OTHER

Social call was given to this group.

Control group

Eligibility Criteria

• Age: 60 Years+
• Sex: all
• Healthy Volunteers: Yes
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• 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

You may not qualify if:

• 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

Sponsors & Collaborators

• The Hong Kong Polytechnic University: lead
• The Queen Elizabeth Hospital: collaborator

Study Sites (1)

Queen Elizabeth Hospital

Kowloon, Hong Kong

Location

Related Publications (1)

• Wong AKC, Wong FKY, Ngai JSC, Hung SYK, Li WC. Effectiveness of a health-social partnership program for discharged non-frail older adults: a pilot study. BMC Geriatr. 2020 Sep 10;20(1):339. doi: 10.1186/s12877-020-01722-5.

  PMID: 32912218 DERIVED

Study Officials

• Arkers KC Wong, Dr

  The Hong Kong Polytechnic University

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: SINGLE
• Who Masked: OUTCOMES ASSESSOR
• Purpose: PREVENTION
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Clinical associate

Study Record Dates

• First Submitted: June 11, 2020
• First Posted: June 17, 2020
• Study Start: June 19, 2017
• Primary Completion: April 30, 2020
• Study Completion: April 30, 2020
• Last Updated: June 17, 2020

Record last verified: 2020-06

Data Sharing

• IPD Sharing: Will not share

Locations

HK (1)