CONNECARE-Assuta-Case Study 1

Assuta Medical Center

Status: Unknown

Conditions: Chronic Disease; Old Age; Debility

Treatments: Device: Connecare self managment system

Study type: Interventional

Funder types: Other

Identifiers

NCT03327233

0033-17-ASMC

Details and patient eligibility

About

The European Union's Horizon 2020 project issued a Call for Action [1] in December 2013 to design, develop, disseminate and evaluate new IT technologies for use in integrative treatment processes, with emphasis on complex adult patient. Assuta Hospital submitted a proposal for this call, as part of a broad consortium of 10 participants from various European countries.

The CONNECARE consortium has formulated a general model for integrative treatment, and is currently in the technological development stages, to create a smart (supportive decision) and adaptive system that supports integrative treatment processes both in the hospital and in the community for personalized treatment in complex chronic patients. The development includes a significant integrative component of self-care management by the patient and / or the primary caregiver.

Following the completion of the technological development, clinical trials will be held in four organizations throughout Europe - Assuta Hospital in Ashdod in cooperation with the Maccabi community in Ashdod, two centers in Catalonia and the Groningen region in the Netherlands. The purpose of the studies is to assess the impact of the implementation of the model, processes and digital tools that will be built during the project.

Full description

The intervention in this study consists of two parts:

1. Integrative treatment in the community, which includes a close follow-up with a coordinating nurse for three months after discharge from the hospital.
2. Empowering the patient to self-manage his or her health by using applications for smart devices.

The study protocol:

1. Recruitment of participants during the patient's hospitalization after the patient is identified as a complex patient, explanation of the study and signing the consent form.
2. Evaluation process for the patient, using valid questionnaires, in order to determine the baseline level at the entrance to the study.
3. Distribution of research kit and related accessories and training.
4. Close monitoring for three months in the community after discharge from the hospital and use of the research kit.
5. Reassessment of the patient at the exit of the study.

Enrollment: 220 estimated patients

Sex: All

Ages: 65+ years old

Volunteers: No Healthy Volunteers

Inclusion criteria

• All Maccabi members who arrive at the ER in an unplanned manner

• Age over 65

• Living in a home and not in a nursing home

• LACE> 7

• At least three of the following conditions:

  • Multiple drugs - regular use of four or more drugs
  • More than one case of hospitalization or visit to the ER in the past year
  • Malnutrition
  • Elements of low socio-economic status

• The patient and / or the main caregiver speak Hebrew, English or Russian

• The patient or primary caregiver has a password to the Maccabi Online website

• The patient and / or the primary caregiver have basic technological knowledge in the use of the applications

• The patient has wireless Internet access at home (via Wifi or through a cellular connection)

Exclusion criteria

• Patients with cognitive or dementia problems

Trial design

Primary purpose: Health Services Research

Allocation: Non-Randomized

Interventional model: Parallel Assignment

Masking: None (Open label)

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220 participants in 2 patient groups

Intervention group

Experimental group

Description:

Implementing the Connecare system to support integrated care for complex patients with an unplanned admission to Assuta Ashdod who are discharged back to the community with an emphasis on Connecare self managment system for the patient and close follow up and coordination of all of the medical, health and social care in the community by a Maccabi integrated care nurse for a period of 3 months post discharge.

Treatment:

Device: Connecare self managment system

Matched control group

No Intervention group

Description:

The control group will be selected from Maccabi's database and will be patients who are matched 1:1 with the intervention sample and live in another community similar to Ashdod in socioeconomic characteristics who undergo the same elective major surgery in other hospitals