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

Study Overview
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Brief Summary
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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
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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.

Official Title
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BeyondSilos - Integrated Care Leading to a More Personalised and Coordinated Care, Improving Outcomes for Elderly Patients, Delivering More Effective Care and Support, and Provide More Cost Efficient Health and Social Services

Conditions
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COPD, Heart Failure, Stroke, Diabetes

Intervention / Treatment
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* Other: New Care


Participation Criteria
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Eligibility Criteria
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Potential participants are selected by screening electronic healthcare and social care records or/and the hospital / national databases and/or during long term condition annual reviews in the community setting. If necessary, candidates are informed about the nature and the objectives of the evaluation. If a candidate passes the inclusion/exclusion criteria and signs the informed consent form, if necessary, they participate in the evaluation. Inclusion Criteria: Age ≥65 years. Presence of health needs specified as: Presence of heart failure, stroke, COPD or diabetes (diagnosed at hospital or at specialist visit) plus at least one additional chronic disease / condition included in the Charlson Comorbidity Index (CCI). Presence of social needs based on Barthel Index of Activities of Daily Living and Instrumental Activities of Daily Living (IADL). Reasonable expectation of permanence in the BeyondSilos project for the whole data collection period (18 months). Informed consent, signed if necessary (by the subject or his/her delegate). Capability to handle ICT equipment / devices alone, or with the help from a delegate. Presence of good/reliable communication connection at home (internet, telephone or what is needed for the ICT connection). Exclusion Criteria: Subjects who have been registered with an active cancer diagnosis and undergoing treatment, has undergone an organ transplant, or is undergoing dialysis prior to enrolment. Subjects in a terminal state People with an AIDS diagnose.

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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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Study Group<br>The Study Group receives 'new care' (integrated health and social care) | Other: New Care<br>* 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<br>* Other names: integrated health care and social care;|
| Comparator Group<br>The comparator group receives usual care | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in length of the hospital stay | Change in the duration of hospitalization (calculated from admission date and discharge date) measured in days | 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 Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Re-hospitalisation period | Re-hospitalisation within 30 days (calculate from admission date and discharge date) measured in days | 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) | 
| Patient encounters | Encounters and contacts between patient and GP, Specialists, Nurse, other involved healthcare providers | 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 | 
| Weight | Weight as disease specific health status measurement | Weight measured in kilo grams (kg) at baseline (month 0) and at end (month 18) of study duration | 
| Blood pressure | Blood pressure as disease specific health status measurement | Blood pressure measured in mmHg at baseline (month 0) and at end (month 18) of study duration | 
| Heart rate | Heart rate pressure as disease specific health status measurement | Heart rate measured in beats per minute (bpm) at baseline and at end of study duration | 
| Oxygen saturation | Oxygen saturation pressure as disease specific health status measurement | Oxygen saturation measured in SpO2 (or %) based on measurement at baseline (month 0) and at end (month 18) of study duration | 
| Blood glucose | Blood glucose pressure as disease specific health status measurement | Blood glucose measured in mg/dl based on measurement at baseline (month 0) and at end (month 18) of study duration | 
| HbA1c | HbA1c pressure as disease specific health status measurement | HbA1c measured in percentage (%) based on measurement at baseline and at end of study duration | 
| Creatinine | Creatinine pressure as disease specific health status measurement | Creatinine measured in mg/dl based on measurement at baseline (month 0) and at end (month 18) of study duration | 
| Charlson Comorbidity Index (CCI) | Charlson Comorbidity Index (CCI) as a generic health related / functional quality of life | 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 | 
| Barthel index | Barthel index as a generic health related / functional quality of life | Barthel index measured in index scale based on measurement at baseline (month 0) and at end (month 18) of study duration | 
| Self-maintaining and instrumental activities of daily living (IADL) | Self-maintaining and instrumental activities of daily living (IADL) as a generic health related / functional quality of life | 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 | 
| Geriatric Depression Scale (GDS Short Form) | Geriatric Depression Scale (GDS Short Form) as a psychological measure | GDS measured in GDSsf-scale based on measurement at baseline (month 0) and at end (month 18) of study duration | 
| Anxiety and depression based on HADS | Anxiety and depression (according to HADScale) as a psychological measure | Anxiety and depression according to HADS-scale measurements based on measurement at baseline (month 0) and at end (month 18) of study duration | 
| PIRU questionnaire on user experience (selected questions) of Integrated Care (IC) | PIRU questionnaire on user experience of IC as a user perspectives measure | User experience (PIRU) measurements based on PIRU-scale measurement at baseline and at end of study duration | 
| End user perception of service utility according to eCCIS (selected questions) | End user perception of service utility (eCCIS) as a user perspectives measure | End user perception of service utility based on eCCIS-scale measurement at baseline (month 0) and at end (month 18) of study duration | 
| Carer perception of service utility according to eCCIS (selected questions) | Carer perception of service utility (eCCIS) as a user perspectives measure | Carer perception of service utility based on eCCIS-scale measurement at baseline (month 0) and at end (month 18) of study duration | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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information technology, telemedicine, integrated care, MAST framework, organizational change, social care, elderly patients