BeyondSilos - Integrated Care Leading to a More Personalised and Coordinated Care, Improving Outcomes for Elderly Patients, Delivering More Effective Care and Support, and Provide More Cost Efficient Health and Social Services
试验速览
- 阶段
- 不适用
- 状态
- 已完成
- 发起方
- 入组人数
- 1,840
- 主要终点
- Change in length of the hospital stay
研究概览
简要总结
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
详细描述
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.
研究设计
- 研究类型
- Observational
- 观察模型
- Cohort
- 时间视角
- Prospective
入排标准
- 年龄范围
- 65 Years 至 —（Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •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).
排除标准
- •Subjects who have been registered with an active cancer diagnosis and undergoing treatment, has undergone an organ transplant, or is undergoing dialysis prior to enrolment.
- •Subjects in a terminal state
- •People with an AIDS diagnose.
结局指标
主要结局
Change in length of the hospital stay
时间窗: 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
次要结局
- 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))
- HbA1c(HbA1c measured in percentage (%) based on measurement at baseline and at end of study duration)
- Barthel index(Barthel index measured in index 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)(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)
- 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)
- 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)
- Blood pressure(Blood pressure measured in mmHg at baseline (month 0) and at end (month 18) of study duration)
- Oxygen saturation(Oxygen saturation measured in SpO2 (or %) based on measurement at baseline (month 0) and at end (month 18) of study duration)
- Blood glucose(Blood glucose measured in mg/dl based on measurement at baseline (month 0) and at end (month 18) of study duration)
- Weight(Weight measured in kilo grams (kg) at baseline (month 0) and at end (month 18) of study duration)
- Creatinine(Creatinine measured in mg/dl based on measurement at baseline (month 0) and at end (month 18) of study duration)
- 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)
- 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)
- Heart rate(Heart rate measured in beats per minute (bpm) at baseline and at end of study duration)
- 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)
- 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)
- 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)