Effectiveness of Integrated Care Network

National Yang Ming Chiao Tung University398 enrolled

Overview

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.

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.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

TREATMENT

Masking

SINGLE

Enrollment

398

Conditions

Fragility Multimorbidity

Interventions

Multi-domain interventionBEHAVIORAL

60 minutes cognitive training, 45 minutes physical exercise, 15 diet nutrition and intermittent disease management consultation

Eligibility

Sex: ALLMin age: 65 Years

Medical Language ↔ Plain English

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

Locations (6)

Hualien Tzu Chi Hospital,Buddhist Tzu Chi Medical Foundation

Hualien City, Taiwan

Shulin Primary Care center

New Taipei City, Taiwan

Yingge Primary Health Care center

New Taipei City, Taiwan

Cheng's primary care clinic

New Taipei City, Taiwan

Outcomes

Primary Outcomes

Changes from baseline life quality at 3, 6, 9, 12 month

measured by the 36-Item Short Form Health Survey (SF-36).

Time frame: baseline, 3, 6, 9, 12 month

Secondary Outcomes

Changes from baseline standard set of health outcome measures for older persons at 3, 6, 9, 12 month

a standard health care set proposed by the International Consortium for Health Outcomes Measurement (ICHOM)

Time frame: baseline, 3, 6, 9, 12 month

Data from ClinicalTrials.gov

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