Partner Communication, Transition
Conditions
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.
Detailed description
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.
Interventions
OTHERComplex 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.
OTHERUsual care
Social call was given to this group.
Sponsors
The Queen Elizabeth Hospital
The Hong Kong Polytechnic University
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
PREVENTION
Masking
SINGLE (Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
60 Years to No maximum
Healthy volunteers
Yes
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
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Change from baseline Health-related quality of life: SF-12 at 3 months | At baseline pre-intervention and at three months when the interventions were completed. | 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. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Change from baseline Activity of daily living at 3 months | At baseline pre-intervention and at three months when the interventions were completed. | Use Modified Barthel index to measure the subjects' ability to do basic activity of daily livings such as grooming, eating, and walking. The score is from 0-100, with higher scores representing better activity of daily living. |
| Change from baseline Presence of depressive symptoms at 3 months | At baseline pre-intervention and at three months when the interventions were completed. | The presence of depressive symptoms was measured by the Geriatric Depression Scale. The scores from each item are summed up. The maximum score is 15, with higher scores representing higher severity of depressive symptoms. Good validity and reliability have been reported in this scale, with criterion-related validity 0.95 and test-retest reliability 0.85 among the older Chinese population. |
| 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. | This information was collected from the subjective reports of participants. They were asked about the number of attendances within the last three months prior to both T1 and T2 data collection. |
Countries
Hong Kong
Outcome results
None listed