Table 1 Measurements and their instruments for patients and caregivers
Measurement | Measurement instruments | Participants | Assessment timepoint |
|---|---|---|---|
Physical function | |||
Ability to perform activities of daily living | Barthel Index [26] | Patient | T0-T5 |
Frailty | 9-point Clinical Frailty Scale [27] | Patient | T0-T5 |
Nutrition status | Mini Nutritional Assessment short-form [28] | Patient | T0-T5 |
Functionality of oral intake | Functional oral intake scale [29] | Patient | T0-T5 |
Risk for pressure injury | The Braden Scale for Predicting Pressure Sore Risk [30] | Patient | T0-T5 |
Drugs for chronic disease | Self-constructed; numbers of drug | Patient | T0-T5 |
Psychological health | |||
Depression | 5-item Geriatric Depression Scale [31] | Patient | T0-T5 |
Neuropsychiatric status | Neuropsychiatric Inventory [32] | Patient | T0-T5 |
Cognitive function | |||
Cognitive function/memory | Brain Health Test (Chinese version, Taiwan) [33] | Patient | T0-T5 |
Severity of Dementia | Functional Assessment Staging Test [34] | Patient | T0-T5 |
Wellbeing | |||
QOL for patients with cognitive impairment | Patient | T0-T5 | |
QOL for people with normal cognition | World Health Organization- Five Well-Being Index [37] | Patient, caregiver | T0-T5 |
Five-level version of EuroQol five-dimensional descriptive system [38] | Patient, caregiver | T0-T5 | |
QOL- Home Care [39] | Patient | T0-T5 | |
SDM and ACP | |||
SDM self-efficacy | Decision-making Participation Self-Efficacy Scale [40] | Patient | T0, T2-T5 |
ACP | 4 questions from ACP engagement survey [41] | Patient | T0, T2-T5 |
Palliative care and quality of dying | |||
Symptoms | Integrated Palliative care Outcome Scale [42] | Patient | T0-T5 |
Needs assessment for supportive & palliative care | Supportive & Palliative Care Indicators Tool [43] | Patient | T0, T2-T5 |
Quality of Dying | Quality of Dying in LTC [44] | Patient | NA a |
Caregiving burden | Revised version of Zarit Burden interview | Caregiver | T0-T5 |
Continuity and coordination of care | Self-constructed; Two items for continuity from hospital to home care, and two items for coordination of home healthcare team and LTC workers, rating with a 7-point Likert-type scale | Patient | T0-T5 |
Care resource utilization and costs | |||
Medical resources | Self-constructed; Items about medical resource utilization and costs | Patient | T0-T1, T3, T5 |
Social welfare/LTC | Self-constructed; Items for the social resource utilization and costs | Patient | T0-T5 |