Effectiveness of Integrated Care Network

Study Overview
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Brief Summary
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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.

Detailed Description
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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.

Official Title
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Effectiveness of Integrated Care Network for Community-living Older Adults: a Randomized-Controlled Trial

Conditions
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Fragility, Multimorbidity

Intervention / Treatment
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* Behavioral: Multi-domain intervention


Participation Criteria
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Eligibility Criteria
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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

Ages Eligible for Study
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Minimum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: Control<br>A regular health education program was provided by case managers only. | |
| Experimental: Intervention<br>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. | Behavioral: Multi-domain intervention<br>* 60 minutes cognitive training, 45 minutes physical exercise, 15 diet nutrition and intermittent disease management consultation<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Changes from baseline life quality at 3, 6, 9, 12 month | measured by the 36-Item Short Form Health Survey (SF-36). | baseline, 3, 6, 9, 12 month | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| 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) | baseline, 3, 6, 9, 12 month | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Integrated Health Care Systems, Multimorbid, Multi-domain intervention, Clinical Trials, Randomized