Effectiveness of Integrated Care Network

National Yang Ming Chiao Tung University

Status: Completed

Conditions: Multimorbidity; Fragility

Treatments: Behavioral: Multi-domain intervention

Study type: Interventional

Funder types: Other

Identifiers

NCT03528005

YM107042F

Details and patient eligibility

About

This project aims to examine the effectiveness of the community-based integrated care service model , based on a multi-domain intervention program, among community-dwelling older adults. Moreover, the investigators use the value-based healthcare standard set as well as comprehensive geriatric assessment as outcome measures and to use the randomized controlled trial design to validate the clinical effectiveness.

Full description

Population aging and the progress of medical technology are two main causes for the increase of healthcare expenditure. Effective management of medical expenditure and maintenance of health care quality have become the most important task for the public health and clinical care services. Both United Kingdom and the World Health Organization proposed introducing interdisciplinary team care to improve health of older people and to maximize their independence. Prof Michael Porter has addressed the current difficulty of healthcare system, and proposed that healthcare system should pursuit long-term outcome to promote the value of health care. This project aims to echo the international trends, using Taiwan healthcare system as the basis to establish the community-based integrated care service model, and to use the randomized controlled trial design to validate the clinical effectiveness.

Enrollment: 398 patients

Sex: All

Ages: 65+ years old

Volunteers: No Healthy Volunteers

Inclusion criteria

• age ≧ 65 years
• three or more chronic conditions, defined by National Health Insurance list of chronic conditions
• covered by National Health Insurance

Exclusion criteria

• could not understanding protocol or communication with research nurses
• malignant diseases under active treatments
• life expectancy less than twelve months
• admitted in the long term facility

Trial design

Primary purpose: Treatment

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: Single Blind

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398 participants in 2 patient groups

Control

No Intervention group

Description:

A regular health education program was provided by case managers only.

Intervention

Experimental group

Description:

Multi-domain intervention included exercise,cognitive training, diet education, and disease consultation was conducted for two hours twice per week in the first month, once per week in the second month, and once per month since third month.

Treatment:

Behavioral: Multi-domain intervention