CONNECARE-Assuta-Case Study 2
Chronic Disease, Old Age; Debility
About this trial
This is an interventional health services research trial for Chronic Disease
Eligibility Criteria
Inclusion Criteria:
- All Maccabi members who were scheduled for a major elective surgery
- Age over 65
- Living in a home and not in a nursing home
- Anesthesiologist ASA score evaluation of levels 2 or 3 only
- Diagnosis of at least one chronic disease of the following - COPD, cardiovascular disease, diabetes, hypertension, cancer or obesity.
- The patient and / or the main caregiver speak Hebrew, English or Russian
- The patient or primary caregiver has a password to the Maccabi Online website
- The patient and / or the primary caregiver have basic technological knowledge in the use of the applications
- The patient has wireless Internet access at home (via Wifi or through a cellular connection)
Exclusion Criteria:
- Patients with cognitive or dementia problems
Sites / Locations
Arms of the Study
Arm 1
Arm 2
Experimental
No Intervention
Intervention group
No Intervention: Matched control group
Implementing the Connecare system to support integrated care for complex patients who are plan to undergo a major elective surgery in Assuta Ashdod and are discharged back to the community with an emphasis on Connecare self managment system for the patient and close follow up and coordination of all of the medical, health and social care in the community for two periods of time: (1) Pre habilitation plan for a month prior to surgery (2) a period of 3 months post discharge.
The control group will be selected from Maccabi's database and will be patients who are matched 1:1 with the intervention sample and live in another community similar to Ashdod in socioeconomic characteristics who undergo the same elective major surgery in other hospitals