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Trial History Detail on 2017-04-27

CUHK_CCRB00554

2017-04-27

Retrospective

2016/17- CRC - MRG - 05

Princess Margaret Hospital Clinical Research Center Mini Research Grant

Princess Margaret Hospital Clinical Research Center

N/A

Not Applicable

Wong Yuk Fong

PMH Community Nursing Service Center
South Wing, 11th Floor, Nurses' Quarter
232 Lai King Hill Road, Kowloon

64610023

wyf811@ha.org.hk

Princess Margaret Hospital

Hong Kong

Wong Yuk Fong

PMH Community Nursing Service Center
South Wing, 11th Floor, Nurses' Quarter
232 Lai King Hill Road, Kowloon

66228247

bonwon62@gmail.com

The Nethersole School of Nursing, The Chinese University of Hong Kong

Hong Kong

The effect of community nurse-led transitional care program to enhance patient and health service utilization outcomes for the older adults with high risk hospital readmissions

The effect of community nurse-led transitional care program to enhance patient and health service utilization outcomes for the older adults with high risk hospital readmissions

社康護士主導之離院後延續家居護理計劃對改善患有慢性疾病的長者健康質素及醫療使用之成效

Hong Kong

Yes

2017-01-04

Kowloon West Cluster Research Ethics Committee

KW/EX-16-180(105-07)

Chronic diseases

Other

Nursing interventions

For the intervention group, the community nurse will conduct patient pre-discharge comprehensive assessments within 48 hours after admission.
Discharge plan will be formulated. The community will follow up them at home for 8 weeks with 8 times home visits with 3 times telephone follow up after discharge. Based on individual needs, home care interventions focus on medication management, symptom management, lifestyle modification, medical follow up and psychological support for patients to enhance their self care in disease management and health maintenance. Structural home care intervention protocol will be followed.

home visit

8 times

8 weeks

8 times home visits within 8 weeks

The control group will receive community nursing service as usual with 8 times home visits and without structural home care protocol interventions

home visit

8 times

8 weeks

8 times home visits

1) Aged 65 or older; 2) with current hospitalization through A&E or at risk of frequent hospital readmissions as indicated by Hospital Admission Risk Reduction Program for the Elderly score equal or greater that 0.2

3) have been diagnosis with one or more chronic Obstruction Pulmonary Disease, Diabetes Mellitus, Hypertension, Congestive Heart Failure

4) Chinese and able to communicate with Cantonese

5) cognitively intact as indicated by Abbreviated Mental Test score ( Hong Kong version) of 6 or more out of 10

6) living within the hospital service area and discharge to home

7) willing to accept community nursing service

Paticipants who are discharged to institutionalized care or followed by a designated disease -specific management program

being under care by Hospital Authority Integrated Care Model Program, Virtual Ward Program or non-governmental organization enhanced home care program, will be excluded

65

999

Both Male and Female

Interventional

Randomized

Randomized Control Trial

Dose comparison

Open label

Parallel

0

2017-05-02

142

Not Yet Recruiting

Primary outcome

the number of hospitalization, emergency room visits and length of hospital stay

T0 ( at discharge), T1 ( 4 weeks after discharge), T2 ( 8 weeks after discharge and when the program is completed), T3 ( 12 weeks after discharge)

Secondary outcome

psychological status by using the Hospital Anxiety and Depression Scale, quality of lifeby using the Chinese version of the EuroQoL - 5 D Questionnaire, self-efficacy by using the Chinese version of the Short form Chronic Disease self-efficacy Scale and satisfaction of care questionnaire

T0( at discharge), T2 ( 8 weeks after discharge and when the program completed )

No

2020-02-18

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