This study aims to 1) develop an Advanced Person-Centered (APC) Smart Home Care Model that is able to predict patient outcomes; and 2) evaluate the effectiveness of this model by assessing improvements in care and recovery for older individuals post hip fracture.
The APC Smart Home Care Model will be developed as follows: a) incorporate a prediction system based on ML data available from our prior studies; b) incorporate an enhanced feedback system using results from the prediction system, which will allow family caregivers to receive timely alerts and facilitate interactions between home care nurses and caregivers; and c) the APC prediction system will be further developed to allow for implementation of targeted home nursing interventions that can be individualized to meet the specific needs of each family caregiver and the person recovering from hip fracture. A mixed-methods approach will be employed to examine the effectiveness of the system, using a combination of quantitative and qualitative data.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Enrollment
218
Enhanced Smart Care Model (SCM) that incorporates precise predictions of adverse outcomes and improvements in the real-time feedback system for caregivers and person-center home-based nursing.
Tuchen Branch Chang Gung Hospital
New Taipei City, Taiwan, Taiwan
Linkuo Chang Gung Memorial Hospital
Taoyuan, Taiwan, Taiwan
Fall Incidents.
number of falls
Time frame: 1st month following discharge
Fall Incidents.
number of falls
Time frame: 3rd month following hospital discharge
Fall insidents
number of falls
Time frame: 6th month following hospital discharge
Fall incidents
Number of falls
Time frame: 12th month following hospital discharge
Fall incidents
Number of falls
Time frame: 18th month following hospital discharge
Fall incidents
Number of falls
Time frame: 24th month following hospital discharge
range of motion
The clinical outcomes to be assessed include range of motion (ROM) in the affected limb in degree
Time frame: 1st month following hospital discharge
Muscle strength of affected limb
maximum amount of force that a muscle can generate during a single contraction. The unit is weights.
Time frame: 1st month following hosptial discharge
Visual analog of Pain score
patient self-report that collected by assessor. Score range 0-100, with higher score indicating more pain.
Time frame: 1st month following hospital discharge
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Barthel Index
assessor measures functional indepdencen in activities of daily living (ADLs) of the patient, score range 0-100, higher score indicate more independent.
Time frame: 1st month following discharge
Lawton IADL scale
Instrumental activities of daily living (ADLs) collected by assessor. Score rage from 0 tto 8, with 8 indicating more independent function.
Time frame: 1st month following discharge
Caregiver balance
The perception of caregivers regarding their ability to manage conflicting caregiving demands. Score range 1-3, with higher score indicating more balance.
Time frame: 1st following hospital discharge
Caregiver balance
The perception of caregivers regarding their ability to manage conflicting caregiving demands. Score range 1-3, with higher score indicating more balance.
Time frame: 3rd month following hospital discharge
Caregiver Balance
The perception of caregivers regarding their ability to manage conflicting caregiving demands. Score range 1-3, with higher score indicating more balance.
Time frame: 6th month following hospital discharge
Caregiver Balance
The perception of caregivers regarding their ability to manage conflicting caregiving demands. Score range 1-3, with higher score indicating more balance.
Time frame: 12th month following hospital discharge
Caregiver Balance
The perception of caregivers regarding their ability to manage conflicting caregiving demands. Score range 1-3, with higher score indicating more balance.
Time frame: 18th month following hospital discharge
Caregiver Balance
The perception of caregivers regarding their ability to manage conflicting caregiving demands. Score range 1-3, with higher score indicating more balance.
Time frame: 24 month following hospital discharge
Caregiver preparedness
Caregiver readiness to handle caregiving responsibilities and associated stresses. Score range 0-32, with higher score indicating more prepared.
Time frame: 1st month following hospital discharge
Caregiver preparedness
Caregiver readiness to handle caregiving responsibilities and associated stresses. Score range 0-32, with higher score indicating more prepared.
Time frame: 3rd month following hospital discharge
Caregiver Preparedness
Caregiver readiness to handle caregiving responsibilities and associated stresses. Score range 0-32, with higher score indicating more prepared.
Time frame: 6th month following hospital discharge
Caregiver Preparedness
Caregiver readiness to handle caregiving responsibilities and associated stresses. Score range 0-32, with higher score indicating more prepared.
Time frame: 12 month following hospital discharge
Caregiver preparedness
Caregiver readiness to handle caregiving responsibilities and associated stresses. Score range 0-32, with higher score indicating more prepared.
Time frame: 18th month following hospital discharge
range of motion
The clinical outcomes to be assessed include range of motion (ROM) in the affected limb in degree
Time frame: 3rd month following hospital discharge
Caregiver Preparedness
Caregiver readiness to handle caregiving responsibilities and associated stresses. Score range 0-32, with higher score indicating more prepared.
Time frame: 24th month following hospital discharge
range of motion
The clinical outcomes to be assessed include range of motion (ROM) in the affected limb in degree
Time frame: 6th month following hospital discharge
range of motion
The clinical outcomes to be assessed include range of motion (ROM) in the affected limb in degree
Time frame: 12th month following hospital discharge
range of motion
The clinical outcomes to be assessed include range of motion (ROM) in the affected limb in degree
Time frame: 18th month following hospital discharge
range of motion
The clinical outcomes to be assessed include range of motion (ROM) in the affected limb in degree
Time frame: 24th month following hospital discharge
Muscle strength of affected limb
maximum amount of force that a muscle can generate during a single contraction. The unit is weights.
Time frame: 3rd month following hosptial discharge
Muscle strength of affected limb
maximum amount of force that a muscle can generate during a single contraction. The unit is weights.
Time frame: 6th month following hosptial discharge
Muscle strength of affected limb
maximum amount of force that a muscle can generate during a single contraction. The unit is weights.
Time frame: 12th month following hosptial discharge
Muscle strength of affected limb
maximum amount of force that a muscle can generate during a single contraction. The unit is weights.
Time frame: 18th month following hosptial discharge
Muscle strength of affected limb
maximum amount of force that a muscle can generate during a single contraction. The unit is weights.
Time frame: 24th month following hosptial discharge
Visual analog of Pain score
patient self-report that collected by assessor. Score range 0-100, with higher score indicating more pain.
Time frame: 3rd month following hospital discharge
Visual analog of Pain score
patient self-report that collected by assessor. Score range 0-100, with higher score indicating more pain.
Time frame: 6th month following hospital discharge
Visual analog of Pain score
patient self-report that collected by assessor. Score range 0-100, with higher score indicating more pain.
Time frame: 12th month following hospital discharge
Visual analog of Pain score
patient self-report that collected by assessor. Score range 0-100, with higher score indicating more pain.
Time frame: 18th month following hospital discharge
Visual analog of Pain score
patient self-report that collected by assessor. Score range 0-100, with higher score indicating more pain.
Time frame: 24th month following hospital discharge
Barthel Index
assessor measures functional indepdencen in activities of daily living (ADLs) of the patient, score range 0-100, higher score indicate more independent.
Time frame: 3rd month following discharge
Barthel Index
assessor measures functional indepdencen in activities of daily living (ADLs) of the patient, score range 0-100, higher score indicate more independent.
Time frame: 6th month following discharge
Barthel Index
assessor measures functional indepdencen in activities of daily living (ADLs) of the patient, score range 0-100, higher score indicate more independent.
Time frame: 12th month following discharge
Barthel Index
assessor measures functional indepdencen in activities of daily living (ADLs) of the patient, score range 0-100, higher score indicate more independent.
Time frame: 18 month following discharge
Barthel Index
assessor measures functional indepdencen in activities of daily living (ADLs) of the patient, score range 0-100, higher score indicate more independent.
Time frame: 24th month following discharge
Lawton IADL scale
Instrumental activities of daily living (ADLs) collected by assessor. Score rage from 0 tto 8, with 8 indicating more independent function.
Time frame: 3rd month following discharge
Lawton IADL scale
Instrumental activities of daily living (ADLs) collected by assessor. Score rage from 0 tto 8, with 8 indicating more independent function.
Time frame: 6th month following discharge
Lawton IADL scale
Instrumental activities of daily living (ADLs) collected by assessor. Score rage from 0 tto 8, with 8 indicating more independent function.
Time frame: 12 month following discharge
Lawton IADL scale
Instrumental activities of daily living (ADLs) collected by assessor. Score rage from 0 tto 8, with 8 indicating more independent function.
Time frame: 18 month following discharge
Lawton IADL scale
Instrumental activities of daily living (ADLs) collected by assessor. Score rage from 0 tto 8, with 8 indicating more independent function.
Time frame: 24 month following discharge
number of visits to emergency department
collected by assessor asking family members
Time frame: 1st month following hospital discharge
number of hospital readmission
collected by assessor by asking family members
Time frame: 1st month following hospital discharge
Cognitive function
Cognitive function following hip-fracture surgery will be assessed using the Taiwan version of the Mini Mental State Examination. Score ranges 0-30, with higher score indicating better cognitive function.
Time frame: 1st month following hospital discharge
Cognitive function
Cognitive function following hip-fracture surgery will be assessed using the Taiwan version of the Mini Mental State Examination. Score ranges 0-30, with higher score indicating better cognitive function.
Time frame: 3rd month following hospital discharge
Cognitive function
Cognitive function following hip-fracture surgery will be assessed using the Taiwan version of the Mini Mental State Examination. Score ranges 0-30, with higher score indicating better cognitive function.
Time frame: 6th month following hospital discharge
Cognitive function
Cognitive function following hip-fracture surgery will be assessed using the Taiwan version of the Mini Mental State Examination. Score ranges 0-30, with higher score indicating better cognitive function.
Time frame: 12th month following hospital discharge
Cognitive function
Cognitive function following hip-fracture surgery will be assessed using the Taiwan version of the Mini Mental State Examination. Score ranges 0-30, with higher score indicating better cognitive function.
Time frame: 18th month following hospital discharge
Cognitive function
Cognitive function following hip-fracture surgery will be assessed using the Taiwan version of the Mini Mental State Examination. Score ranges 0-30, with higher score indicating better cognitive function.
Time frame: 24th month following hospital discharge
Depressive symptoms
Patients' depressive symptoms will be evaluated using the 15-item Geriatric Depression Scale, short form (GDS-SF). Score range 0-15, with higher score indicating higher depressive symptoms.
Time frame: 1st month following hospital discharge
Depressive symptoms
Patients' depressive symptoms will be evaluated using the 15-item Geriatric Depression Scale, short form (GDS-SF). Score range 0-15, with higher score indicating higher depressive symptoms.
Time frame: 3rd month following hospital discharge
Depressive symptoms
Patients' depressive symptoms will be evaluated using the 15-item Geriatric Depression Scale, short form (GDS-SF). Score range 0-15, with higher score indicating higher depressive symptoms.
Time frame: 6th month following hospital discharge
Depressive symptoms
Patients' depressive symptoms will be evaluated using the 15-item Geriatric Depression Scale, short form (GDS-SF). Score range 0-15, with higher score indicating higher depressive symptoms.
Time frame: 12th month following hospital discharge
Depressive symptoms
Patients' depressive symptoms will be evaluated using the 15-item Geriatric Depression Scale, short form (GDS-SF). Score range 0-15, with higher score indicating higher depressive symptoms.
Time frame: 18th month following hospital discharge
Depressive symptoms
Patients' depressive symptoms will be evaluated using the 15-item Geriatric Depression Scale, short form (GDS-SF). Score range 0-15, with higher score indicating higher depressive symptoms.
Time frame: 24th month following hospital discharge
Nutritional Status
The 18-item Mini Nutritional Assessment (MNA). Score range 0-30, with higher score indicating better nutritioanl status.
Time frame: 1st month following hospital discharge
Nutritional Status
The 18-item Mini Nutritional Assessment (MNA). Score range 0-30, with higher score indicating better nutritioanl status.
Time frame: 3rd month following hospital discharge
Nutritional Status
The 18-item Mini Nutritional Assessment (MNA). Score range 0-30, with higher score indicating better nutritioanl status.
Time frame: 6th month following hospital discharge
Nutritional Status
The 18-item Mini Nutritional Assessment (MNA). Score range 0-30, with higher score indicating better nutritioanl status.
Time frame: 12th month following hospital discharge
Nutritional Status
The 18-item Mini Nutritional Assessment (MNA). Score range 0-30, with higher score indicating better nutritioanl status.
Time frame: 18th month following hospital discharge
Nutritional Status
The 18-item Mini Nutritional Assessment (MNA). Score range 0-30, with higher score indicating better nutritioanl status.
Time frame: 24th month following hospital discharge
Health-Related Quality of Life (HRQoL)
Taiwan version of the 36-item Short Form Survey (SF-36). Score range 0-100, with higher score indicating better health outcomes.
Time frame: 1st month following hospital discharge
Health-Related Quality of Life (HRQoL)
Taiwan version of the 36-item Short Form Survey (SF-36). Score range 0-100, with higher score indicating better health outcomes.
Time frame: 3rd month following hospital discharge
Health-Related Quality of Life (HRQoL)
Taiwan version of the 36-item Short Form Survey (SF-36). Score range 0-100, with higher score indicating better health outcomes.
Time frame: 6th month following hospital discharge
Health-Related Quality of Life (HRQoL)
Taiwan version of the 36-item Short Form Survey (SF-36). Score range 0-100, with higher score indicating better health outcomes.
Time frame: 12th month following hospital discharge
Health-Related Quality of Life (HRQoL)
Taiwan version of the 36-item Short Form Survey (SF-36). Score range 0-100, with higher score indicating better health outcomes.
Time frame: 18th month following hospital discharge
Health-Related Quality of Life (HRQoL)
Taiwan version of the 36-item Short Form Survey (SF-36). Score range 0-100, with higher score indicating better health outcomes.
Time frame: 24th month following hospital discharge
number of visits to emergency department
collected by assessor asking family members
Time frame: 3rd month following hospital discharge
number of visits to emergency department
collected by assessor asking family members
Time frame: 6th month following hospital discharge
number of visits to emergency department
collected by assessor asking family members
Time frame: 12th month following hospital discharge
number of visits to emergency department
collected by assessor asking family members
Time frame: 18th month following hospital discharge
number of visits to emergency department
collected by assessor asking family members
Time frame: 24th month following hospital discharge
number of hospital readmission
collected by assessor by asking family members
Time frame: 3rd month following hospital discharge
number of hospital readmission
collected by assessor by asking family members
Time frame: 6th month following hospital discharge
number of hospital readmission
collected by assessor by asking family members
Time frame: 12 month following hospital discharge
number of hospital readmission
collected by assessor by asking family members
Time frame: 18th month following hospital discharge
number of hospital readmission
collected by assessor by asking family members
Time frame: 24 month following hospital discharge