Digital Care for Holistic Health in Older Adults With Diabetes and Multimorbidity

Chang Gung University of Science and Technology

Status: Invitation-only

Conditions: Gout Arthritis; Hypertension; Type2Diabetes; CKD; Dyslipidemia; Cardio Vascular Disease

Treatments: Behavioral: Digital Care Community Common Good Program; Behavioral: Usual Care

Study type: Interventional

Funder types: Other

Identifiers

NCT07310849

IRB 24 021 B1

Details and patient eligibility

About

The purpose of this study was to explore the effectiveness of the "Digital Care Community Common Good" program in improving disease control indicators, self-management abilities, depression, and quality of life among patients with comorbidities and type 2 diabetes. The study was designed as a two-year experimental study, with a specific area in New Taipei City selected as the research site. In the first year, the main tasks include establishing an integrated intervention team composed of primary healthcare providers and community resources, expanding the functionalities of the mHealth platform, developing digital educational materials for diabetes comorbidities care, and recruiting and training 6 to 8 community care volunteers. Additionally, 169 eligible participants with type 2 diabetes and comorbidities will be recruited from four communities, completing baseline assessments and randomization into groups. In the second year, a 6-month intervention and effectiveness evaluation of the " Digital Care Community Common Good " program will be implemented. The intervention includes online and in-person educational sessions, telephone care, use of the mHealth platform (featuring educational, data monitoring, contextual learning, interactive, and reminders), as well as home visits, case discussions, and individualized care plans for high-risk cases. Disease control indicators, selfmanagement abilities, depression, and quality of life will be tracked immediately post-intervention, at 3 month, and at 6 month to assess outcomes and changes over time. This study expects to enhance health management for diabetes patients with comorbidities through digital care and interdisciplinary collaboration, offering evidence-based insights and recommendations for policy implementation in the integration of community and primary healthcare models.

Enrollment: 169 estimated patients

Sex: All

Ages: 50+ years old

Volunteers: No Healthy Volunteers

Inclusion criteria

1. Age and Consent: Individuals aged 50 years or older who are willing to provide written informed consent.
2. Language and Literacy: Participants must be literate and able to communicate in Mandarin or Taiwanese.
3. Medical Diagnosis: Participants must have a physician-confirmed diagnosis of type 2 diabetes mellitus (T2DM) and at least one comorbid chronic disease (e.g., hypertension, hyperlipidemia, chronic kidney disease, or heart disease).
4. Technology Use: Participants must own a smartphone and be willing to use the LINE messaging app and web-based health education links.
5. Residence: Participants must reside within one of the four participating communities and have no plans to move away during the study intervention period.

Exclusion criteria

• (1)Those with severe diabetes-related complications, such as renal failure, cerebrovascular disease, diabetic foot, or retinopathy.

  (2)Individuals with psychiatric disorders, undergoing active cancer treatment, or those unable to perform independent self-care (e.g., due to visual impairment or mobility limitations).

  (3)Individuals without diabetes but with other chronic diseases. (4)Individuals residing in long-term care institutions. (5)Individuals who are simultaneously participating in other intervention programs.

Trial design

Primary purpose: Health Services Research

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: Double Blind

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169 participants in 2 patient groups

The experimental group receives usual care and a 6-month Digital Care Community Common Good program

Experimental group

Description:

online and in-person educational sessions, telephone care, use of the mHealth platform (featuring educational, data monitoring, contextual learning, interactive, and reminders), as well as home visits, case discussions, and individualized care plans for high-risk cases.

Treatment:

Behavioral: Digital Care Community Common Good Program

The control group that receives usual care and the local integrated medical network information

Other group

Description:

receives usual care and the local integrated medical network information, including clinics and healthcare institutes that provide comorbidity care and counseling.

Treatment:

Behavioral: Usual Care