Telehealth-Supported Discharge Programme for Frail Older Adults

NCT07490847 | Not Yet Recruiting

• 1 other identifier: CIRB-2025-552-5
• Study Type: interventional
• Target: 50
• Locations: 1 country
• Sites: 1

Brief Summary

This pilot clinical trial aims to evaluate the feasibility, acceptability, and preliminary effectiveness of a telehealth-supported discharge programme on physical and mental health outcomes, and healthcare utilization among community-dwelling older adults with frailty after hospital discharge. The objectives are:

1. 1.To determine the feasibility and acceptability of the programme by assessing participant recruitment, retention, adherence rates, and satisfaction;
2. 2.To evaluate the preliminary effects of the programme on a) physical health outcomes (e.g., physical fitness, activities of daily living), b) mental health outcomes (e.g., depressive symptoms, perceived social support, quality of life, subjective well-being), and c) healthcare utilization (e.g., emergency department visits, hospital readmissions); and
3. 3.To identify perceived barriers and facilitators of the programme and evaluate the acceptability and usability of gerontechnology activity sensors and pedometers for monitoring activity levels.

Conditions

Frailty

Keywords

Frailty; Hospital Discharge; Older Adults; Psychoeducation; Reablement; Randomized Controlled Trial

Outcome Measures

Primary Outcomes (1)

• Physical fitness

  Physical fitness will be assessed using the Senior Fitness Test (SFT), which is comprised of seven tests that evaluate body strength, flexibility, agility, aerobic capacity, and body composition. The tests include the following: 30-second chair stand, 30-second arm curl, 2-minute step test, chair sit-and-reach, back scratch, 8-foot-up-and-go, and 2-minute step-in-place test. Each component is scored separately using standardized units (e.g., number of repetitions, distance, or time), with higher scores generally indicating better physical fitness, except for timed tests (e.g., 8-foot up-and-go), where lower times indicate better performance.

  Baseline (T0) and upon intervention completion at 12 weeks (T1)

Secondary Outcomes (6)

• Activities of daily living

  Baseline (T0) and upon intervention completion at 12 weeks (T1)

• Instrumental activities of daily living

  Baseline (T0) and upon intervention completion at 12 weeks (T1)

• Depressive symptoms

  Baseline (T0) and upon intervention completion at 12 weeks (T1)

• Perceived social support

  Baseline (T0) and upon intervention completion at 12 weeks (T1)

• Health-related quality of life

  Baseline (T0) and upon intervention completion at 12 weeks (T1)

Other Outcomes (3)

• Hospital readmissions

  Upon intervention completion at 12 weeks (T1)

• Unplanned visits to the emergency department

  Upon intervention completion at 12 weeks (T1)

• Hospital length of stay

  Upon intervention completion at 12 weeks (T1)

Study Arms (2)

Telehealth discharge support programme

EXPERIMENTAL

Behavioral: Telehealth discharge support programme

Usual care

NO INTERVENTION

Participants assigned to the control group will continue to receive usual care. Usual care typically includes home visits and/or follow-up calls by community nurses focused on medication management and basic health education, as needed.

Interventions

Telehealth discharge support programme BEHAVIORAL

The 12-week telehealth-supported discharge programme consists of weekly one hour virtual sessions consisting of didactic and experiential activities to support recovery after hospital discharge. Sessions focus on improving physical activity and mobility through home-based exercises, strengthening self-management skills related to frailty, promoting mental resilience and well-being, and providing opportunities for peer interaction and social support. Additionally, one activity sensor will be installed in the homes of participants within the intervention group to monitor and evaluate their physical activity levels and patterns over time. The advanced smart home activity sensors, equipped with AI capabilities, will enable remote monitoring of daily activity patterns among participants. A pedometer will also be provided to participants as a motivational tool to reduce sedentary behaviour.

Telehealth discharge support programme

Eligibility Criteria

• Age: 65 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Older Adult (65+)

You may qualify if:

• Aged 65 years or older;
• Able to speak Cantonese;
• Meet the operational definition of frailty, which is defined as an individual who scores 3 or more on the 5-item FRAIL scale, which reflects fatigue, resistance, ambulation, illnesses, and weight loss;
• Are mentally competent according to the Abbreviated Mental Test (AMT ≥ 6);
• Discharged from an acute hospital within the last two weeks and residing at home; and
• Have access to a digital device with internet connectivity, such as a smartphone, tablet, or computer

You may not qualify if:

• Currently undergoing active psychiatric treatment for severe mental illness (e.g., schizophrenia, bipolar disorder) that result in serious functional impairment
• Experiencing medical conditions that contraindicate physical exercise (e.g., recent acute myocardial infarction, unstable cardiovascular pathology, fracture within the past month); and/or
• Presenting with any significant visual, language, or communication impairments that would impede their ability to meaningfully engage with the programme

Sponsors & Collaborators

• Chinese University of Hong Kong: lead
• United Christian Hospital: collaborator

Study Sites (1)

The Chinese University of Hong Kong

Shatin, New Territories, Hong Kong

Location

MeSH Terms

Conditions

Frailty

Condition Hierarchy (Ancestors)

Pathologic Processes; Pathological Conditions, Signs and Symptoms

Central Study Contacts

Sarah Xiao

CONTACT

+852 3943 1502; sarahxiao@cuhk.edu.hk

Study Design

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

Study Record Dates

• First Submitted: March 6, 2026
• First Posted: March 24, 2026
• Study Start: April 1, 2026
• Primary Completion (Estimated): March 31, 2027
• Study Completion (Estimated): March 31, 2027
• Last Updated: March 24, 2026

Record last verified: 2026-03

Locations

HK (1)