BeyondSilos - More Personalised and Coordinated Care and Improved Outcomes for Elderly Patients "BeyondSilos"

Active, not recruiting

Phase N/A Results N/A

Trial Description

The study evaluates the impact of the new organisational models developed in the framework of the BeyondSilos pilot service in order to provide ICT supported integrated health and social care to elderly patients

Detailed Description

The overall aim of the evaluation carried out in BeyondSilos is to identify the differences introduced by implementing ICT supported integrated care in different domains according to the MAST evaluation framework, including safety, clinical and social outcomes, resource use and cost of care, user/carer experience and organisational changes.
The focus of the evaluation will be the impact of so called "horizontal" integration, which is the integration between social care and health care, and the changing organisational models for elderly patients.
The hypothesis in this study is that integrated care (IC) will lead to a more personalised and coordinated care, improve outcomes for elderly patients, deliver more effective care and support, and provide more cost efficient health and social services.

Conditions

Interventions

  • New Care Other
    Other Names: integrated health care and social care
    Intervention Desc: All settings that are in any way relevant to the provision of health and social care are integrated, including: out-of-hospital (community) services as well as hospitals, GPs' offices, community nurses, and any type of care practitioners, users' homes and volunteer service providers' offices
    ARM 1: Kind: Experimental
    Label: Study Group
    Description: The Study Group receives 'new care' (integrated health and social care)

Trial Population

Elderly living independently at home with diagnosed chronic disease(s).

Outcomes

Type Measure Time Frame Safety Issue
Primary Change in length of the hospital stay Days between admission and discharge of patient's admission episodes, measured based on follow up during whole length of study and accumulated at END of study (at month 18)
Secondary Re-hospitalisation period Days between last discharge of patient and her/his re-hospitalization, measured based on follow up during whole length of study and accumulated at END of study (at month 18)
Secondary Patient encounters Number of registered encounters/contacts between patient and GP, Specialists, Nurse, other involved healthcare providers within the timeframe based on total count in period between start (month 0) end (month 18) of study
Secondary Weight Weight measured in kilo grams (kg) at baseline (month 0) and at end (month 18) of study duration
Secondary Blood pressure Blood pressure measured in mmHg at baseline (month 0) and at end (month 18) of study duration
Secondary Heart rate Heart rate measured in beats per minute (bpm) at baseline and at end of study duration
Secondary Oxygen saturation Oxygen saturation measured in SpO2 (or %) based on measurement at baseline (month 0) and at end (month 18) of study duration
Secondary Blood glucose Blood glucose measured in mg/dl based on measurement at baseline (month 0) and at end (month 18) of study duration
Secondary HbA1c HbA1c measured in percentage (%) based on measurement at baseline and at end of study duration
Secondary Creatinine Creatinine measured in mg/dl based on measurement at baseline (month 0) and at end (month 18) of study duration
Secondary Charlson Comorbidity Index (CCI) Charlson Comorbidity Index (CCI) measured in (a) ICD-10-CM and (b) CCI scale based on measurement at baseline (month 0) and at end (month 18) of study duration
Secondary Barthel index Barthel index measured in index scale based on measurement at baseline (month 0) and at end (month 18) of study duration
Secondary Self-maintaining and instrumental activities of daily living (IADL) Self-maintaining and instrumental activities of daily living (IADL) measured in (IADL) scale based on measurement at baseline (month 0) and at end (month 18) of study duration
Secondary Geriatric Depression Scale (GDS Short Form) GDS measured in GDSsf-scale based on measurement at baseline (month 0) and at end (month 18) of study duration
Secondary Anxiety and depression based on HADS Anxiety and depression according to HADS-scale measurements based on measurement at baseline (month 0) and at end (month 18) of study duration
Secondary PIRU questionnaire on user experience (selected questions) of Integrated Care (IC) User experience (PIRU) measurements based on PIRU-scale measurement at baseline and at end of study duration
Secondary End user perception of service utility according to eCCIS (selected questions) End user perception of service utility based on eCCIS-scale measurement at baseline (month 0) and at end (month 18) of study duration
Secondary Carer perception of service utility according to eCCIS (selected questions) Carer perception of service utility based on eCCIS-scale measurement at baseline (month 0) and at end (month 18) of study duration

Sponsors