Development and Validation of a Comprehensive Management Service Package for Older Adults With Multimorbidity

This study aims to test a new comprehensive management service package for older adults with two or more chronic conditions (multimorbidity). The package includes digital health tools, personalized guidance, and long-term management support. Researchers will compare the service package with usual care to see whether it reduces hospital readmissions, improves quality of life, and supports daily functioning. About 394 participants will be randomly assigned to either the service package group or the usual care group. Participants will be followed for 6 months to measure health outcomes, treatment adherence, and safety.

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Key information

Conditions

Multimorbidity Arterial Occlusive Diseases Arteriosclerosis Arthritis Brain Diseases Cardiovascular Diseases Central Nervous System Diseases Cerebrovascular Disorders Chronic Disease Chronic Kidney Disease Chronic Liver Diseases Cognition Disorders Cognitive Dysfunction Cognitive Impairment Coronary Artery Disease Coronary Disease Depression - Major Depressive Disorder Diabetes Mellitus Disease Attributes Dyslipidemia Dyslipidemias Endocrine System Diseases Female Urogenital Diseases Female Urogenital Diseases and Pregnancy Complications Glucose Metabolism Disorders Heart Diseases Hypertension Joint Diseases Kidney Diseases Lipid Metabolism Disorders Male Urogenital Diseases Mental Disorders Metabolic Diseases Musculoskeletal Diseases Myocardial Ischemia Nervous System Diseases Neurocognitive Disorders Nutritional and Metabolic Diseases Pathologic Processes Pathological Conditions, Signs and Symptoms Renal Insufficiency Renal Insufficiency, Chronic Stroke Urogenital Diseases Urologic Diseases Vascular Diseases

Age range

65 year and older

Sex eligibility

All sexes

Study type

Interventional

Phase

Not applicable

About this study

The goal of this clinical trial is to learn if a new comprehensive management service package can help improve health outcomes for older adults who have two or more chronic conditions (multimorbidity). It will also learn about the safety, acceptability, and cost-effectiveness of the service package.

The main questions it aims to answer are:

Does the service package lower the number of hospital readmissions in older adults with multimorbidity?
Does it improve quality of life, daily function (intrinsic capacity), and treatment adherence?
What are the costs and potential risks of using the service package compared to usual care? Researchers will compare the service package to usual care (no service package).

Participants will:

Be randomly assigned to either the service package group or the usual care group
Use the digital tools and health management support included in the service package (such as apps, monitoring devices, and personalized health guidance)
Receive regular follow-up visits and surveys over 6 months to track their health, hospital use, and satisfaction

Who can participate

Healthy volunteers accepted: No

Only the study team can determine whether someone qualifies for participation.

Inclusion criteria

Age ≥65 years
Diagnosed with ≥2 chronic diseases or geriatric syndromes (e.g., hypertension, diabetes, frailty, depression)
Willing to provide informed consent

Exclusion criteria

Life expectancy <1 year due to severe illness (e.g., cardiogenic shock)
Currently participating in other clinical trials

Treatment and study plan

Service Package Group

Device

patients receive comprehensive multimorbidity management service package (digital tools, MDT decision support, lifestyle interventions, long-term management tools).

Primary outcomes

Hospital readmission rate

Time frame: 6 months

Hospital readmission rate

Study contacts

Contact information is provided by the study sponsor or research team.

Yin Chun Lin, PhD

CONTACT

[email protected]

8613552566227

Sponsors and collaborators

Lead sponsor

Xuanwu Hospital, Beijing

Other

Registry information

Official study title

Development and Validation of a Comprehensive Management Service Package for Older Adults With Multimorbidity: A Randomized Controlled Trial

Acronym: COMPASS

Important dates

Study start: 2025
Primary completion: 2026
Study completion: 2026
First posted: Sep 3, 2025
Registry last updated: Sep 3, 2025

OpenTrials presents study information sourced from ClinicalTrials.gov. The official registry record should be consulted for the latest information.

View the official ClinicalTrials.gov record (opens in a new tab)

This listing is for discovery and informational purposes only. It is not medical advice, does not guarantee that a study is recruiting, and does not determine eligibility. Contact the study team and a qualified healthcare professional when considering participation.

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Completed