NCT04434742

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

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

• Status: Completed
• Phase: N/A
• Study type: Interventional
• Enrollment: 75 (actual)
• Sponsor: The Hong Kong Polytechnic University · Academic / Other
• Sex: All
• Age: 60 Years
• Healthy volunteers: Accepted

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.

Conditions

• Transition
• Partner Communication

Interventions

Type	Name	Description
OTHER	Complex 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.
OTHER	Usual care	Social call was given to this group.

Timeline

• Start date: 2017-06-19
• Primary completion: 2020-04-30
• Completion: 2020-04-30
• First posted: 2020-06-17
• Last updated: 2020-06-17

Locations

1 site across 1 country: Hong Kong