Evaluation of an Integrated Home Care Model
For patients and families
In plain language
An automatic summary of structured registry data. It is an orientation aid, not a substitute for the official protocol or a physician assessment.
- What is being studied
- The protocol lists: ADMIT integrated care Program.
- Who it may be relevant to
- Registry conditions: Older Adults (70 or More) Living at Home With Health and Social Complexity. Basic parameters: from 70 years · All.
- What needs checking
- Age, condition and sex are only basic indicators. Prior treatment, laboratory values and other mandatory requirements appear in the eligibility criteria below.
- Where it takes place
- Spain
- Next step
- Save the trial, show it to the treating physician, and confirm current recruitment with the study center. Costs, documents and travel →
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Official title
Integrated Home Care (ADMIT). Transforming the Model of Home Care Though Technology and Integrated Health and Social Care
Overview
The demographic shift towards a progressive aging of the population represents an unprecedented challenge for Western societies and for the sustainability of health and social systems. Hypotheses: A complex, multi-component intervention based on integrated home care, facilitated by technological tools and focused on the frail person with complex needs (ADMIT Program): * Will increase at least 5% of the days spent at home compared to usual care * Will reduce exacerbations or health or social crisis at home * Will improve the quality of life and well-being of users and their informal caregiver * Will improve the experience of the people cared for, their caregivers and professionals in the health and social systems Main objective: To evaluate the effectiveness of the ADMIT program in increasing the % of days at home of frail elderly people compared to usual practice. Secondary objectives: To evaluate the effectiveness of the ADMIT program compared to usual care to reduce exacerbations or situations of crisis that motivate emergency care or hospitalizations. To evaluate the incremental cost-utility ratio of the ADMIT program in relation to usual practice, exploring different time horizons and different scenarios of population scalability. To evaluate the experience of the people treated, their informal caregivers and professionals. To identify the determinants of change and contextual factors of the program implementation process Methodology: Hybrid evaluation model that allows evaluating the process, effectiveness, safety and cost-utility while implementing the intervention in real life. Mixed methods, typical of implementation science, will be used, with different stages: First stage: co-creation of the care model and the technological platform with the participation of users and professionals Second stage: evaluation of the process, results and experience through a pragmatic randomized controlled trial with a batched stepped wedge design and comparison with a parallel "external" control group, matched using propensity score techniques. Applicability and Relevance: The ADMIT program is aligned with the current trend and the shared interest of evolving towards integrated social and health care, keeping people with complex needs in their homes for as long as possible and with the best possible quality of life. The ADMIT project is an implementation project supported by the Catalan Health Department and the Integrated Care Agency. The technological platform that will be co-created and piloted is expected to be adopted by Catalan Health Department for its scaling up in the territory.
Interventions
- Other ADMIT integrated care Program
Participants will be attended following an integrated care program which is being co-created by professionals, patients and caregivers, with the following principles: 1. Proactive detection of candidates from both sides (the health and the social services); 2. Designation of a reference and a co-reference professional, one from each side; 3. Shared situational diagnosis based on a comprehensive geriatric assessment; 4. Definition of a shared individual care pathway; 5. Shared follow up. Using a
Primary outcome measures
- Percentage of days at home [Time frame: During the intervention (6 months from the baseline).]
Eligibility criteria
Inclusion criteria
- Living at home AND
- Adjusted Morbidity Group = 3 or 4 or high risk OR Complex or Advanced frailty or chronicity OR Home health care program; AND
- Dependent for the basic daily activities OR Social complexity (SSM-CAT positive) OR Dependency grade= 1, 2 or 3 OR Lack of social support OR Home social care program OR Living alone
Exclusion criteria
- Living in a nursing home
- Unable to make decisions about care (either by the patient or the caregiver)
- Person with needs that exceed the coverage of the program
- Not providing informed consent
Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.
Healthy volunteers: No
Study design
- Allocation
- Randomized
- Model
- Sequential
- Masking
- Single blind
- Primary purpose
- Supportive care
Study locations
Spain · 8 centers
- CAP Larrard — Barcelona
- CAP Sarrià — Barcelona
- EBA Vallcarca — Barcelona
- Institut Municipal de Serveis Socials - Ajuntament de Barcelona — Barcelona
- Institut Català de la Salut - Girona — Girona
- Consorci Acció Social La Garrotxa — Olot
- Fundació Hospital d'Olot i Comarcal de la Garrotxa — Olot
- Programa de Gestió d'Atenció a la Complexitat (PGAC) — Vic
Identifiers
NCT: NCT07408882 · PT-072023-EP