Model of care
The community-based health-social partnership (CHSP) program is built on two main conceptual guides: Supported self-care and the Omaha System. The concept of supported self-care references the UK framework for promoting health and social partnership, which aims at supporting people in the community with long-term conditions . At the delivery end, individualized case management was employed to support patients with enhanced knowledge, skills and confidence in caring for themselves. Efforts were directed at building a community-based intervention with a health-social partnership to ensure that system resources and collaboration among stakeholders could be activated to provide support to individuals when needed. There was a case manager to ensure that the support for individual clients in enhancing self-care was comprehensive and properly coordinated. The nurse, backed up by a multidisciplinary team, assumed the role of case manager in the program, and home visits and telephone calls were the two approaches to care delivery [15, 16]. The Omaha System was used as a comprehensive assessment-intervention-evaluation framework in this study to provide the skeleton for translating the concept of supported self-care. The Omaha System has been widely used in community health settings . It has a very clear and comprehensive description of the assessment and intervention schemes. The clear description of the schemes facilitates the classification of the problems and the nature of the required intervention, thus leading to effective inter-professional collaboration.
Study design, setting, and participants
This was a single-blind, randomized controlled trial. Subject recruitment took place in the emergency medical ward (EMW) of a hospital in Hong Kong. The EMW is an extension of the Accident and Emergency service, with a total of 36 beds. Patients were included if they resided in the service areas of the study hospital, were aged 60 or over, were cognitively competent with a score greater than 26 in the Montreal Cognitive Assessment Hong Kong version , were living at home before and after discharge from the EMW, had scores of < 5 on the Clinical Frailty Scale (Note: a patient is considered to be non-frail if they have a score less than 5) , and were fit for medical discharge. Patients who were not able to communicate, could not be reached by phone, were bed-bound, had active psychiatric problems, were already engaged in other structured health or social programs, and would not be staying in Hong Kong for the three months of the study were excluded. A research assistant introduced the program including its aim, benefits, and the potential risks of participating to eligible patients. Patients who agreed to participate would sign a consent form. Ethical approval was obtained from the ethics committee of the hospital before data collection (REC No. 17–0015/FR-3). The reporting of this trial follows the CONSORT guideline (www.consort-statement.org).
A research team member who was not involved in the subject recruitment and data collection generated a random assignment schedule using the software Research Randomizer. The assignment of groups was put in sealed envelopes. The research team member, upon successfully recruiting a subject, opened an envelope in sequence after the enrolled subjects had finished the baseline assessment, and allocated the subject to the assigned intervention or control group. In this study, the research assistant who collected the data was blinded but the patients and provider involved in the intervention were not.
Power calculations were not conducted for the pilot study , because the data collected from the pilot study will be used to inform sample size estimation and power analysis for a future large-scale study. A systematic review , however, found that a general rule for pilot studies is to take 30 patients per arm. With reference to the 10% attrition reported in previous programs for community-dwelling older adults , a sample size of 66 patients was used in this study.
This is a three-month health-social partnership program. The first month acted as a loading dose, where more intensive support was provided to older adults post-discharge. The second and third months were considered as a maintenance dose, representing the continuation of the intervention to sustain the therapeutic effect.
After each client was admitted to the EMW, an advanced practice nurse (APN) from a hospital discharge team visited them to familiarize him/herself with their condition and prepare a discharge plan. A face-to-face or telephone call handover between the APN and the project nurse case manager (NCM) was performed before the client was discharged. The past and current medical conditions, medical and nursing management, and follow-up appointments were discussed. After discharge home, the NCM, functioning as the leader of health-social care team, conducted the initial assessment in the first home visit to identify the client’s health and social problems within one week of discharge. Community workers, supervised by both the nurse case manager and social worker, provided telephone follow-up and subsequent home visits to monitor the client’s progress and provide support when necessary.
The Omaha System was used by the NCM in the first home visit because it provides categories to connect the home health care problems of post-discharged non-frail older adults to the related nursing interventions. According to the problems identified, the NCM provided interventions in accordance with the Omaha System scheme, which included health teaching, guidance and counseling, treatment and procedures, case management and surveillance. The NCM also coordinated care across a range of settings, from the home to the community center or hospital when necessary. In order to provide better care to clients, interdisciplinary case conferences were held regularly between the NCM and social workers, with the involvement of the APN if appropriate. During the conference, the health-social team members communicated each other’s role in managing the case, which increased understanding and collaboration in the process. In addition, events such as the progress and concerns of clients, and suggestions for further actions, modifications, or adjustment of interventions were reviewed.
The control group received usual discharge care and community resources that were made available to them as appropriate. A monthly social call was made to each client in the control group in order to exclude social effects. The social call was provided by a research team member who was not involved in data collection. The contents of the social call, such as asking about entertainment and clients’ hobbies, were set in the protocol.
Data were collected at two time intervals—at baseline pre-intervention (T1) and at three months when the interventions were completed – to determine the effects of the study (T2). Health-related quality of life (HRQoL) was used as the primary outcome measure of the study. The goal for this program was to enable older adults to live with optimum quality of life in their own environment through receiving support from the collaboration of nurse case managers and social workers. Quality of life was measured by SF-12, which has been shown to be useful in Chinese elderly patients . The questionnaire has 12 items organized into eight categories (physical functioning, role limitation due to emotional and physical problems, mental health scale, general health, bodily pain, social functioning, and vitality), and has been validated in numerous studies . The Cronbach’s alpha coefficient was 0.7 .
Secondary outcomes included activities of daily living (ADL), the presence of depressive symptoms, and the use of health services. ADL was measured by the Chinese version of the Modified Barthel Index . The presence of depressive symptoms was measured by the Geriatric Depression Scale . Good validity and reliability were shown in these two measuring scales among the Chinese elderly population [25,26,27].
The outcome of health service use included the total number of unplanned outpatient department, general practitioner, and emergency department visits, hospital admissions and total number of health service attendances. This information was collected from the subjective reports of participants. They were asked about the number of attendances within the last three months prior to both T1 and T2 data collection.
Statistical tests were performed using the Statistical Package for Social Sciences (SPSS) version 23 software. The principles of intention-to-treat analysis were followed. Descriptive analyses were used for describing the baseline demographic data. The independent t-test or the Mann-Whitney U test analyzed the group differences in HRQoL, ADL, and presence of depressive symptoms according to the normality of data. The time differences between T1 and T2 were analyzed using the paired t-test or Wilcoxon’s signed rank test. Logistic regression and Chi-squared tests were used to analyze health service use in dichotomized outcomes (i.e. health service use and no unplanned service use). Adjusted and unadjusted models were performed in all cases where regression modelling was done. Variables including sex, age, household composition, and financial status were adjusted, since they are likely to affect outcomes . Odds ratios (OR) with 95% confidence intervals (CI) were calculated and reported. A multiple imputation procedure was employed to impute the missing data .