Help Optimise and Mobilise Elders (H.O.M.E) (HOME)

During hospitalisations, older inpatients commonly face issues such as immobility, loss of independence, and functional decline. This leads them down the cascade of dependency with consequent increased risk of adverse outcomes, institutionalisation as well as higher post-acute care costs. The investigators hypothesize that by implementing a mobility intervention in the inpatient setting, patients would be able to maintain their function upon discharge and avoid the cascade of dependency. As such, the investigators aim to do this by implementing and evaluating a mobility intervention, while optimising reversible factors affecting mobility among inpatients admitted to a geriatric unit in Singapore. The investigators will also examine the cost impact of a mobility focused model of care and also adopt the effectiveness-implementation hybrid Type 2 design where both effectiveness and implementation spheres are tested simultaneously.

Study Overview

• Status: Not yet recruiting
• Conditions: Mobility Limitation; Functional Disturbance
• Intervention / Treatment: Other: Multicomponent, mobility-focused intervention

Detailed Description

Aim 1: To examine the effectiveness of multicomponent, mobility-focused model of care in reducing iatrogenic complications and improving patient outcomes. Adopting the Institute for Healthcare Improvement's (IHI) 4Ms framework ("Mobility", "Mentation, "Medication", and "What Matters"), the investigators will examine the effectiveness of timely and individually catered mobility interventions which not only increase mobilization but also optimize factors inhibiting mobility for elderly inpatients. It is hypothesized that the mobility outcomes, such as maximum distance walked and mobilization frequency will be significantly improved for patients who receive the intervention compared to those who receive standard care.

Aim 2: To examine the cost impact of a mobility-focused model of care. The investigators will examine whether the cost of these multicomponent, mobility-focused interventions can be offset from cost savings from early mobilisation benefits, by comparing healthcare utilization costs between-groups. Further to that, a cost effectiveness analysis will be performed should functional effectiveness be observed. For the primary cost impact objective, it is hypothesized that the cost savings arising from reduction in bed days of hospitalization and other medical costs incurred during study period will outweigh the cost of implementing this model of care. In addition, it is also hypothesized that the proposed intervention will be cost-effective through achieving better functional outcomes for patients, with lower costs required.

Aim 3: To evaluate the implementation outcomes of multicomponent, mobility-focused model of care in the process of this intervention. It is hypothesized that this intervention will have good acceptability, feasibility, penetration, implementation costs and sustainability.

• Study Type: Interventional
• Enrollment (Anticipated): 90
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Melanie Tan Dr; Phone Number: 67165237; Email: melanie_tan@nuhs.edu.sg

Study Locations

• Singapore
  • Singapore, Singapore, 609606
    • Ng Teng Fong Hospital
    • Contact: Melanie Tan Dr; Phone Number: 67165237; Email: melanie_tan@nuhs.edu.sg
    • Sub-Investigator: Seok Mei Lim Dr
    • Sub-Investigator: Dina Ee Dr
    • Sub-Investigator: Weng Kin Lai
    • Sub-Investigator: Russell Yoong
    • Sub-Investigator: Lydia Au Dr
    • Sub-Investigator: Bing Kit Chan
  • Singapore, Singapore, 768024
    • Geriatrics Education and Research Institute
    • Contact: Lau Lay Khoon Dr; Phone Number: 68078031; Email: lau.charlene.lk@geri.com.sg
    • Sub-Investigator: Tou Nien Xiang Dr
    • Sub-Investigator: Ding Yew Yoong Prof
    • Sub-Investigator: Michelle Jessica Pereira Dr

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 21 years to 110 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Newly admitted patients to the geriatric service
• Aged 75 years and above
• Mobile with or without the use of a walking aid

Exclusion Criteria:

• Vancomycin-resistant enterococcus (VRE) status
• Requires droplet or airborne precautions
• Critically ill
• Haemodynamically instability
• Requires more than 4-hourly parameters
• Systolic blood pressure <90 mmHg
• Heart rate >100beats/min
• Non-ambulant patients
• With advanced dementia (Functional Assessment Staging Scale [FAST] 7 dementia)
• Fulfills direct admission to another subspecialty unit

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Non-Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Intervention; Intervention group will receive a multicomponent, mobility-focused intervention during the course of inpatient admission.	Other: Multicomponent, mobility-focused intervention; The intervention group will receive early therapist review (within one working day of admission to HOME unit), to be mobilised at least three times a day. They will also receive additional group exercise therapy sessions, as well as nurse screening for geriatric syndromes. Besides that, they will be screened for 4Ms (Mobility, Mentation, Medication, What Matters) by doctor on admission.
No Intervention: Control; The control group will receive usual care as per current ward practice.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in maximum distance walked	The total distance covered by the research participant (in meter)	Upon admission and at the point of discharge (an average of 10 days after inclusion. Analysis will take into account the variability of length of stay)
Mobilisation frequency	Number of times mobilised. The average mobilisation frequency will be calculated by dividing the sum by the number of admission days.	Through the duration of admission

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in modified barthel score	The score ranges from 0 to 100 with 0 as the worst outcome	Upon admission, at discharge (an average of 10 days after inclusion. Analysis will take into account the variability of length of stay), and one-month post discharge
Change in gait speed	4 meter gait speed test (meter/second)	Upon admission and at discharge (an average of 10 days after inclusion. Analysis will take into account the variability of length of stay)
Inpatient length of stay and discharge location	The duration of admission (days) and the location the respective participant is discharged to	The duration of admission and upon discharge (an average of 10 days after inclusion. Analysis will take into account the variability of length of stay)
Presence of common iatrogenic complications such as delirium, injurious falls, pressure ulcers, and venous thromboembolisms	Each of the complication will be measured in nominal scale; 0 denotes the absence of the complication while 1 denotes the presence of the complications. The total number of complications arise will be calculated. The greater the number indicates poorer outcome	At discharge (an average of 10 days after inclusion. Analysis will take into account the variability of length of stay)
Gross amount of patient's bill during index admission, considering subsidy level	The total gross amount of participant's bill during index admission. The subsidy level will be documented	At discharge (an average of 10 days after inclusion. Analysis will take into account the variability of length of stay)
The intervention related costs for group therapy	The number of group therapy sessions attended by the participant multiply by the cost for one group therapy session. The subsidy level will be documented.	At discharge (an average of 10 days after inclusion. Analysis will take into account the variability of length of stay)

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Mortality	1 denotes survival while 0 denotes the participant passed away	1-month follow-up post-discharge
Readmission	The number of readmission due to the index admission within 30 days post discharged	1-month follow-up post-discharge
Healthcare utilisation data and associated costs	Number of visits (associated with index admission) to emergency department, specialist outpatient clinic, general practitioner and the associated costs within 30 days post-discharged	1-month follow-up post-discharge
Ambulatory status	Self-reported by the participant. Four options: 0 denotes bed-bound, 1 denotes chair-bound, 2 denotes assisted (furniture cruiser, walking frame, rollator frame, quadstick, single point stick); 4 denotes independent	1-month follow-up post-discharge
Fall	0 denotes no fall; 1 denotes fall(s) occured (within 30days post-discharged)	1-month follow-up post-discharge
Utilisation of community resources	Self-reported by the participant: Five options: 0 denotes home care; 1 denotes day care; 2 denotes meals on wheels; 3 denotes medical escort service; 4 denotes home personal care	1-month follow-up post-discharge

Collaborators and Investigators

• Sponsor: JurongHealth
• Collaborators: National Healthcare Group, Singapore; Geriatric Education and Research Institute
• Investigators: Principal Investigator: Melanie Tan Dr, Ng Teng Fong General Hospital; Principal Investigator: Lau Lay Khoon Dr, Geriatric Education and Research Institute

Publications and helpful links

General Publications

• Durlak JA, DuPre EP. Implementation matters: a review of research on the influence of implementation on program outcomes and the factors affecting implementation. Am J Community Psychol. 2008 Jun;41(3-4):327-50. doi: 10.1007/s10464-008-9165-0.
• Graham ID, Logan J, Harrison MB, Straus SE, Tetroe J, Caswell W, Robinson N. Lost in knowledge translation: time for a map? J Contin Educ Health Prof. 2006 Winter;26(1):13-24. doi: 10.1002/chp.47.
• Olson EV, Johnson BJ, Thompson LF. The hazards of immobility. 1967. Am J Nurs. 1990 Mar;90(3):43-8. No abstract available.
• Hirsch CH, Sommers L, Olsen A, Mullen L, Winograd CH. The natural history of functional morbidity in hospitalized older patients. J Am Geriatr Soc. 1990 Dec;38(12):1296-303. doi: 10.1111/j.1532-5415.1990.tb03451.x.
• Mate KS, Berman A, Laderman M, Kabcenell A, Fulmer T. Creating Age-Friendly Health Systems - A vision for better care of older adults. Healthc (Amst). 2018 Mar;6(1):4-6. doi: 10.1016/j.hjdsi.2017.05.005. Epub 2017 Aug 1.
• Surkan MJ, Gibson W. Interventions to Mobilize Elderly Patients and Reduce Length of Hospital Stay. Can J Cardiol. 2018 Jul;34(7):881-888. doi: 10.1016/j.cjca.2018.04.033. Epub 2018 May 9.
• Smith TO, Sreekanta A, Walkeden S, Penhale B, Hanson S. Interventions for reducing hospital-associated deconditioning: A systematic review and meta-analysis. Arch Gerontol Geriatr. 2020 Sep-Oct;90:104176. doi: 10.1016/j.archger.2020.104176. Epub 2020 Jul 6.
• Murray ME, Wells TJ, Callen BL. Hospital resource utilization and functional decline of geriatric patients. Nurs Econ. 2003 May-Jun;21(3):114-9. No abstract available.
• Loyd C, Markland AD, Zhang Y, Fowler M, Harper S, Wright NC, Carter CS, Buford TW, Smith CH, Kennedy R, Brown CJ. Prevalence of Hospital-Associated Disability in Older Adults: A Meta-analysis. J Am Med Dir Assoc. 2020 Apr;21(4):455-461.e5. doi: 10.1016/j.jamda.2019.09.015. Epub 2019 Nov 14.
• Wu HY, Sahadevan S, Ding YY. Factors associated with functional decline of hospitalised older persons following discharge from an acute geriatric unit. Ann Acad Med Singap. 2006 Jan;35(1):17-23.
• Boyd CM, Landefeld CS, Counsell SR, Palmer RM, Fortinsky RH, Kresevic D, Burant C, Covinsky KE. Recovery of activities of daily living in older adults after hospitalization for acute medical illness. J Am Geriatr Soc. 2008 Dec;56(12):2171-9. doi: 10.1111/j.1532-5415.2008.02023.x.
• Inouye SK, Bogardus ST Jr, Baker DI, Leo-Summers L, Cooney LM Jr. The Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in older hospitalized patients. Hospital Elder Life Program. J Am Geriatr Soc. 2000 Dec;48(12):1697-706. doi: 10.1111/j.1532-5415.2000.tb03885.x.
• Liu B, Moore JE, Almaawiy U, Chan WH, Khan S, Ewusie J, Hamid JS, Straus SE; MOVE ON Collaboration. Outcomes of Mobilisation of Vulnerable Elders in Ontario (MOVE ON): a multisite interrupted time series evaluation of an implementation intervention to increase patient mobilisation. Age Ageing. 2018 Jan 1;47(1):112-119. doi: 10.1093/ageing/afx128.
• Hastings SN, Sloane R, Morey MC, Pavon JM, Hoenig H. Assisted early mobility for hospitalized older veterans: preliminary data from the STRIDE program. J Am Geriatr Soc. 2014 Nov;62(11):2180-4. doi: 10.1111/jgs.13095. Epub 2014 Oct 30.
• Hastings SN, Choate AL, Mahanna EP, Floegel TA, Allen KD, Van Houtven CH, Wang V. Early Mobility in the Hospital: Lessons Learned from the STRIDE Program. Geriatrics (Basel). 2018 Dec;3(4):61. doi: 10.3390/geriatrics3040061. Epub 2018 Sep 26.
• Smart DA, Dermody G, Coronado ME, Wilson M. Mobility Programs for the Hospitalized Older Adult: A Scoping Review. Gerontol Geriatr Med. 2018 Nov 1;4:2333721418808146. doi: 10.1177/2333721418808146. eCollection 2018 Jan-Dec.
• Hoyer EH, Friedman M, Lavezza A, Wagner-Kosmakos K, Lewis-Cherry R, Skolnik JL, Byers SP, Atanelov L, Colantuoni E, Brotman DJ, Needham DM. Promoting mobility and reducing length of stay in hospitalized general medicine patients: A quality-improvement project. J Hosp Med. 2016 May;11(5):341-7. doi: 10.1002/jhm.2546. Epub 2016 Feb 5.
• Lim SH, Ang SY, Ong HK, Lee TZY, Lee TXL, Luo EZ, Thilarajah S. Promotion of mobility among hospitalised older adults: An exploratory study on perceptions of patients, carers and nurses. Geriatr Nurs. 2020 Sep-Oct;41(5):608-614. doi: 10.1016/j.gerinurse.2020.03.015. Epub 2020 Apr 5.
• Chan EY, Samsudin SA, Lim YJ. Older patients' perception of engagement in functional self-care during hospitalization: A qualitative study. Geriatr Nurs. 2020 May - Jun;41(3):297-304. doi: 10.1016/j.gerinurse.2019.11.009. Epub 2019 Nov 29.
• Raymond MJ, Jeffs KJ, Winter A, Soh SE, Hunter P, Holland AE. The effects of a high-intensity functional exercise group on clinical outcomes in hospitalised older adults: an assessor-blinded, randomised-controlled trial. Age Ageing. 2017 Mar 1;46(2):208-213. doi: 10.1093/ageing/afw215.
• Wallin M, Talvitie U, Cattan M, Karppi SL. Construction of group exercise sessions in geriatric inpatient rehabilitation. Health Commun. 2008;23(3):245-52. doi: 10.1080/10410230802055349.
• Renner CIe, Outermans J, Ludwig R, Brendel C, Kwakkel G, Hummelsheim H. Group therapy task training versus individual task training during inpatient stroke rehabilitation: a randomised controlled trial. Clin Rehabil. 2016 Jul;30(7):637-48. doi: 10.1177/0269215515600206. Epub 2015 Aug 27.
• Kongkasuwan R, Voraakhom K, Pisolayabutra P, Maneechai P, Boonin J, Kuptniratsaikul V. Creative art therapy to enhance rehabilitation for stroke patients: a randomized controlled trial. Clin Rehabil. 2016 Oct;30(10):1016-1023. doi: 10.1177/0269215515607072. Epub 2015 Sep 22.
• Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, Griffey R, Hensley M. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011 Mar;38(2):65-76. doi: 10.1007/s10488-010-0319-7.
• Lavis JN, Lomas J, Hamid M, Sewankambo NK. Assessing country-level efforts to link research to action. Bull World Health Organ. 2006 Aug;84(8):620-8. doi: 10.2471/blt.06.030312. Erratum In: Bull World Health Organ. 2006 Oct;84(10):840.

Study record dates

Study Major Dates

• Study Start (Anticipated): July 25, 2022
• Primary Completion (Anticipated): January 31, 2023
• Study Completion (Anticipated): September 30, 2023

Study Registration Dates

• First Submitted: June 25, 2022
• First Submitted That Met QC Criteria: August 1, 2022
• First Posted (Actual): August 2, 2022

Study Record Updates

• Last Update Posted (Actual): August 2, 2022
• Last Update Submitted That Met QC Criteria: August 1, 2022
• Last Verified: June 1, 2022

More Information

Terms related to this study

• Keywords: Elderly; Mobility; Geriatric; Group therapy; length of stay; Inpatient; Functional Decline; Mobility Intervention; Gait speed; Maximum distance walked; Cost impact; Multidisciplinary; Implementation study; 4Ms (Mobility, Mentation, Medication, What Matters); Nursing screen
• Additional Relevant MeSH Terms: Mobility Limitation
• Other Study ID Numbers: GERI1627

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: Yes
• IPD Plan Description: Working together with Geriatric Education and Research Institute and National Healthcare Group (Health Services & Outcomes Research).
• IPD Sharing Time Frame: During study period.
• IPD Sharing Access Criteria: Via secure platforms (files to be encrypted with password). For the purposes of data sharing and data analysis.
• IPD Sharing Supporting Information Type: Study Protocol; Statistical Analysis Plan (SAP); Informed Consent Form (ICF); Clinical Study Report (CSR); Analytic Code

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No