Integrated Home Care Program Using Technology to Support Frail Older Adults Living at Home Improving Care and Quality of Life Through Health and Social Services Collaboration

What this Trial Is About

Researchers are evaluating an integrated home care program called ADMIT for older adults aged 70 or more who live at home and face complex health and social needs. The study aims to see if this multi-component intervention, which uses technology and coordinated care, can increase the percentage of days these individuals spend at home compared to usual care. Additional goals include reducing health crises, improving quality of life for patients and their caregivers, and assessing the programs cost-effectiveness and overall experience. Participants will be randomly assigned to either receive usual care or the ADMIT program, which is co-created by professionals, patients, and caregivers. The ADMIT program involves proactive candidate detection from health and social services, assignment of reference professionals from both sectors, shared diagnosis and individualized care plans, and ongoing shared follow-up. A technological platform supports communication and information sharing among all parties, with optional use of sensors and robotic devices to assist home care. During the six-month intervention, researchers will track the percentage of days participants spend at home, monitor health and social crises, and gather feedback on experiences from patients, caregivers, and professionals. The study uses mixed methods to evaluate effectiveness, safety, and cost-utility in real-world settings, with an overall goal to support aging individuals in their homes while improving care quality and system sustainability.

Evaluation of an Integrated Home Care Model