COPD, Diabetes, Heart Failure, Stroke
Conditions
Keywords
information technology, telemedicine, integrated care, MAST framework, organizational change, social care, elderly patients
Brief summary
The study evaluates the impact of the new organisational models developed in the framework of the BeyondSilos pilot service in order to provide ICT supported integrated health and social care to elderly patients
Detailed description
The overall aim of the evaluation carried out in BeyondSilos is to identify the differences introduced by implementing ICT supported integrated care in different domains according to the MAST evaluation framework, including safety, clinical and social outcomes, resource use and cost of care, user/carer experience and organisational changes. The focus of the evaluation will be the impact of so called horizontal integration, which is the integration between social care and health care, and the changing organisational models for elderly patients. The hypothesis in this study is that integrated care (IC) will lead to a more personalised and coordinated care, improve outcomes for elderly patients, deliver more effective care and support, and provide more cost efficient health and social services.
Interventions
OTHERNew Care
All settings that are in any way relevant to the provision of health and social care are integrated, including: out-of-hospital (community) services as well as hospitals, GPs' offices, community nurses, and any type of care practitioners, users' homes and volunteer service providers' offices
Sponsors
Him SA
Study design
Observational model
COHORT
Time perspective
PROSPECTIVE
Eligibility
Sex/Gender
ALL
Age
65 Years to No maximum
Healthy volunteers
No
Inclusion criteria
Potential participants are selected by screening electronic healthcare and social care records or/and the hospital / national databases and/or during long term condition annual reviews in the community setting. If necessary, candidates are informed about the nature and the objectives of the evaluation. If a candidate passes the inclusion/
Exclusion criteria
and signs the informed consent form, if necessary, they participate in the evaluation. Inclusion Criteria: * Age ≥65 years. * Presence of health needs specified as: Presence of heart failure, stroke, COPD or diabetes (diagnosed at hospital or at specialist visit) plus at least one additional chronic disease / condition included in the Charlson Comorbidity Index (CCI). * Presence of social needs based on Barthel Index of Activities of Daily Living and Instrumental Activities of Daily Living (IADL). * Reasonable expectation of permanence in the BeyondSilos project for the whole data collection period (18 months). * Informed consent, signed if necessary (by the subject or his/her delegate). * Capability to handle ICT equipment / devices alone, or with the help from a delegate. * Presence of good/reliable communication connection at home (internet, telephone or what is needed for the ICT connection).
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Change in length of the hospital stay | Days between admission and discharge of patient's admission episodes, measured based on follow up during whole length of study and accumulated at END of study (at month 18) | Change in the duration of hospitalization (calculated from admission date and discharge date) measured in days |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Patient encounters | Number of registered encounters/contacts between patient and GP, Specialists, Nurse, other involved healthcare providers within the timeframe based on total count in period between start (month 0) end (month 18) of study | Encounters and contacts between patient and GP, Specialists, Nurse, other involved healthcare providers |
| Weight | Weight measured in kilo grams (kg) at baseline (month 0) and at end (month 18) of study duration | Weight as disease specific health status measurement |
| Blood pressure | Blood pressure measured in mmHg at baseline (month 0) and at end (month 18) of study duration | Blood pressure as disease specific health status measurement |
| Heart rate | Heart rate measured in beats per minute (bpm) at baseline and at end of study duration | Heart rate pressure as disease specific health status measurement |
| Oxygen saturation | Oxygen saturation measured in SpO2 (or %) based on measurement at baseline (month 0) and at end (month 18) of study duration | Oxygen saturation pressure as disease specific health status measurement |
| Blood glucose | Blood glucose measured in mg/dl based on measurement at baseline (month 0) and at end (month 18) of study duration | Blood glucose pressure as disease specific health status measurement |
| HbA1c | HbA1c measured in percentage (%) based on measurement at baseline and at end of study duration | HbA1c pressure as disease specific health status measurement |
| Creatinine | Creatinine measured in mg/dl based on measurement at baseline (month 0) and at end (month 18) of study duration | Creatinine pressure as disease specific health status measurement |
| Re-hospitalisation period | Days between last discharge of patient and her/his re-hospitalization, measured based on follow up during whole length of study and accumulated at END of study (at month 18) | Re-hospitalisation within 30 days (calculate from admission date and discharge date) measured in days |
| Barthel index | Barthel index measured in index scale based on measurement at baseline (month 0) and at end (month 18) of study duration | Barthel index as a generic health related / functional quality of life |
| Self-maintaining and instrumental activities of daily living (IADL) | Self-maintaining and instrumental activities of daily living (IADL) measured in (IADL) scale based on measurement at baseline (month 0) and at end (month 18) of study duration | Self-maintaining and instrumental activities of daily living (IADL) as a generic health related / functional quality of life |
| Geriatric Depression Scale (GDS Short Form) | GDS measured in GDSsf-scale based on measurement at baseline (month 0) and at end (month 18) of study duration | Geriatric Depression Scale (GDS Short Form) as a psychological measure |
| Anxiety and depression based on HADS | Anxiety and depression according to HADS-scale measurements based on measurement at baseline (month 0) and at end (month 18) of study duration | Anxiety and depression (according to HADScale) as a psychological measure |
| PIRU questionnaire on user experience (selected questions) of Integrated Care (IC) | User experience (PIRU) measurements based on PIRU-scale measurement at baseline and at end of study duration | PIRU questionnaire on user experience of IC as a user perspectives measure |
| End user perception of service utility according to eCCIS (selected questions) | End user perception of service utility based on eCCIS-scale measurement at baseline (month 0) and at end (month 18) of study duration | End user perception of service utility (eCCIS) as a user perspectives measure |
| Carer perception of service utility according to eCCIS (selected questions) | Carer perception of service utility based on eCCIS-scale measurement at baseline (month 0) and at end (month 18) of study duration | Carer perception of service utility (eCCIS) as a user perspectives measure |
| Charlson Comorbidity Index (CCI) | Charlson Comorbidity Index (CCI) measured in (a) ICD-10-CM and (b) CCI scale based on measurement at baseline (month 0) and at end (month 18) of study duration | Charlson Comorbidity Index (CCI) as a generic health related / functional quality of life |
Outcome results
None listed