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NCT Number: NCT07419789

Precision Care for Older Persons

This study aims to 1) develop an Advanced Person-Centered (APC) Smart Home Care Model that is able to predict patient outcomes; and 2) evaluate the effectiveness of this model by assessing improvements in care and recovery for older individuals post hip fracture.

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Key information

Conditions

Hip Fractures Femoral Fractures Fractures, Bone Hip Injuries Leg Injuries Wounds and Injuries

Age range

60 year–120 year

Sex eligibility

All sexes

Study type

Interventional

Phase

Not applicable

Primary location

Tuchen Branch Chang Gung Hospital, New Taipei City, Taiwan

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About this study

The APC Smart Home Care Model will be developed as follows: a) incorporate a prediction system based on ML data available from our prior studies; b) incorporate an enhanced feedback system using results from the prediction system, which will allow family caregivers to receive timely alerts and facilitate interactions between home care nurses and caregivers; and c) the APC prediction system will be further developed to allow for implementation of targeted home nursing interventions that can be individualized to meet the specific needs of each family caregiver and the person recovering from hip fracture. A mixed-methods approach will be employed to examine the effectiveness of the system, using a combination of quantitative and qualitative data.

Who can participate

Healthy volunteers accepted: No

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

Inclusion criteria

  • ≥ 60 years old,
  • had been transferred from the emergency department to the hospital due to a unilateral hip fracture,
  • repair of the hip fracture involved either hip arthroplasty or internal fixation, 4) their primary place of residence was northern Taiwan

Exclusion criteria

  • severity of cognitive impairment (a CMMSE score of < 10),
  • known to be terminally ill,
  • has no primary family caregiver,
  • residing in an institutional care facility

Treatment and study plan

Advanced Person-Centered (APC) Smart Home Care Model

Behavioral

Enhanced Smart Care Model (SCM) that incorporates precise predictions of adverse outcomes and improvements in the real-time feedback system for caregivers and person-center home-based nursing.

Primary outcomes

  1. Fall Incidents.

    Time frame: 1st month following discharge

    number of falls

  2. Fall Incidents.

    Time frame: 3rd month following hospital discharge

    number of falls

  3. Fall insidents

    Time frame: 6th month following hospital discharge

    number of falls

  4. Fall incidents

    Time frame: 12th month following hospital discharge

    Number of falls

  5. Fall incidents

    Time frame: 18th month following hospital discharge

    Number of falls

  6. Fall incidents

    Time frame: 24th month following hospital discharge

    Number of falls

  7. range of motion

    Time frame: 1st month following hospital discharge

    The clinical outcomes to be assessed include range of motion (ROM) in the affected limb in degree

  8. Muscle strength of affected limb

    Time frame: 1st month following hosptial discharge

    maximum amount of force that a muscle can generate during a single contraction. The unit is weights.

  9. Visual analog of Pain score

    Time frame: 1st month following hospital discharge

    patient self-report that collected by assessor. Score range 0-100, with higher score indicating more pain.

  10. Barthel Index

    Time frame: 1st month following discharge

    assessor measures functional indepdencen in activities of daily living (ADLs) of the patient, score range 0-100, higher score indicate more independent.

  11. Lawton IADL scale

    Time frame: 1st month following discharge

    Instrumental activities of daily living (ADLs) collected by assessor. Score rage from 0 tto 8, with 8 indicating more independent function.

  12. Caregiver balance

    Time frame: 1st following hospital discharge

    The perception of caregivers regarding their ability to manage conflicting caregiving demands. Score range 1-3, with higher score indicating more balance.

  13. Caregiver balance

    Time frame: 3rd month following hospital discharge

    The perception of caregivers regarding their ability to manage conflicting caregiving demands. Score range 1-3, with higher score indicating more balance.

  14. Caregiver Balance

    Time frame: 6th month following hospital discharge

    The perception of caregivers regarding their ability to manage conflicting caregiving demands. Score range 1-3, with higher score indicating more balance.

  15. Caregiver Balance

    Time frame: 12th month following hospital discharge

    The perception of caregivers regarding their ability to manage conflicting caregiving demands. Score range 1-3, with higher score indicating more balance.

  16. Caregiver Balance

    Time frame: 18th month following hospital discharge

    The perception of caregivers regarding their ability to manage conflicting caregiving demands. Score range 1-3, with higher score indicating more balance.

  17. Caregiver Balance

    Time frame: 24 month following hospital discharge

    The perception of caregivers regarding their ability to manage conflicting caregiving demands. Score range 1-3, with higher score indicating more balance.

  18. Caregiver preparedness

    Time frame: 1st month following hospital discharge

    Caregiver readiness to handle caregiving responsibilities and associated stresses. Score range 0-32, with higher score indicating more prepared.

  19. Caregiver preparedness

    Time frame: 3rd month following hospital discharge

    Caregiver readiness to handle caregiving responsibilities and associated stresses. Score range 0-32, with higher score indicating more prepared.

  20. Caregiver Preparedness

    Time frame: 6th month following hospital discharge

    Caregiver readiness to handle caregiving responsibilities and associated stresses. Score range 0-32, with higher score indicating more prepared.

  21. Caregiver Preparedness

    Time frame: 12 month following hospital discharge

    Caregiver readiness to handle caregiving responsibilities and associated stresses. Score range 0-32, with higher score indicating more prepared.

  22. Caregiver preparedness

    Time frame: 18th month following hospital discharge

    Caregiver readiness to handle caregiving responsibilities and associated stresses. Score range 0-32, with higher score indicating more prepared.

  23. range of motion

    Time frame: 3rd month following hospital discharge

    The clinical outcomes to be assessed include range of motion (ROM) in the affected limb in degree

  24. Caregiver Preparedness

    Time frame: 24th month following hospital discharge

    Caregiver readiness to handle caregiving responsibilities and associated stresses. Score range 0-32, with higher score indicating more prepared.

  25. range of motion

    Time frame: 6th month following hospital discharge

    The clinical outcomes to be assessed include range of motion (ROM) in the affected limb in degree

  26. range of motion

    Time frame: 12th month following hospital discharge

    The clinical outcomes to be assessed include range of motion (ROM) in the affected limb in degree

  27. range of motion

    Time frame: 18th month following hospital discharge

    The clinical outcomes to be assessed include range of motion (ROM) in the affected limb in degree

  28. range of motion

    Time frame: 24th month following hospital discharge

    The clinical outcomes to be assessed include range of motion (ROM) in the affected limb in degree

  29. Muscle strength of affected limb

    Time frame: 3rd month following hosptial discharge

    maximum amount of force that a muscle can generate during a single contraction. The unit is weights.

  30. Muscle strength of affected limb

    Time frame: 6th month following hosptial discharge

    maximum amount of force that a muscle can generate during a single contraction. The unit is weights.

  31. Muscle strength of affected limb

    Time frame: 12th month following hosptial discharge

    maximum amount of force that a muscle can generate during a single contraction. The unit is weights.

  32. Muscle strength of affected limb

    Time frame: 18th month following hosptial discharge

    maximum amount of force that a muscle can generate during a single contraction. The unit is weights.

  33. Muscle strength of affected limb

    Time frame: 24th month following hosptial discharge

    maximum amount of force that a muscle can generate during a single contraction. The unit is weights.

  34. Visual analog of Pain score

    Time frame: 3rd month following hospital discharge

    patient self-report that collected by assessor. Score range 0-100, with higher score indicating more pain.

  35. Visual analog of Pain score

    Time frame: 6th month following hospital discharge

    patient self-report that collected by assessor. Score range 0-100, with higher score indicating more pain.

  36. Visual analog of Pain score

    Time frame: 12th month following hospital discharge

    patient self-report that collected by assessor. Score range 0-100, with higher score indicating more pain.

  37. Visual analog of Pain score

    Time frame: 18th month following hospital discharge

    patient self-report that collected by assessor. Score range 0-100, with higher score indicating more pain.

  38. Visual analog of Pain score

    Time frame: 24th month following hospital discharge

    patient self-report that collected by assessor. Score range 0-100, with higher score indicating more pain.

  39. Barthel Index

    Time frame: 3rd month following discharge

    assessor measures functional indepdencen in activities of daily living (ADLs) of the patient, score range 0-100, higher score indicate more independent.

  40. Barthel Index

    Time frame: 6th month following discharge

    assessor measures functional indepdencen in activities of daily living (ADLs) of the patient, score range 0-100, higher score indicate more independent.

  41. Barthel Index

    Time frame: 12th month following discharge

    assessor measures functional indepdencen in activities of daily living (ADLs) of the patient, score range 0-100, higher score indicate more independent.

  42. Barthel Index

    Time frame: 18 month following discharge

    assessor measures functional indepdencen in activities of daily living (ADLs) of the patient, score range 0-100, higher score indicate more independent.

  43. Barthel Index

    Time frame: 24th month following discharge

    assessor measures functional indepdencen in activities of daily living (ADLs) of the patient, score range 0-100, higher score indicate more independent.

  44. Lawton IADL scale

    Time frame: 3rd month following discharge

    Instrumental activities of daily living (ADLs) collected by assessor. Score rage from 0 tto 8, with 8 indicating more independent function.

  45. Lawton IADL scale

    Time frame: 6th month following discharge

    Instrumental activities of daily living (ADLs) collected by assessor. Score rage from 0 tto 8, with 8 indicating more independent function.

  46. Lawton IADL scale

    Time frame: 12 month following discharge

    Instrumental activities of daily living (ADLs) collected by assessor. Score rage from 0 tto 8, with 8 indicating more independent function.

  47. Lawton IADL scale

    Time frame: 18 month following discharge

    Instrumental activities of daily living (ADLs) collected by assessor. Score rage from 0 tto 8, with 8 indicating more independent function.

  48. Lawton IADL scale

    Time frame: 24 month following discharge

    Instrumental activities of daily living (ADLs) collected by assessor. Score rage from 0 tto 8, with 8 indicating more independent function.

Secondary outcomes

  1. number of visits to emergency department

    Time frame: 1st month following hospital discharge

    collected by assessor asking family members

  2. number of hospital readmission

    Time frame: 1st month following hospital discharge

    collected by assessor by asking family members

  3. Cognitive function

    Time frame: 1st month following hospital discharge

    Cognitive function following hip-fracture surgery will be assessed using the Taiwan version of the Mini Mental State Examination. Score ranges 0-30, with higher score indicating better cognitive function.

  4. Cognitive function

    Time frame: 3rd month following hospital discharge

    Cognitive function following hip-fracture surgery will be assessed using the Taiwan version of the Mini Mental State Examination. Score ranges 0-30, with higher score indicating better cognitive function.

  5. Cognitive function

    Time frame: 6th month following hospital discharge

    Cognitive function following hip-fracture surgery will be assessed using the Taiwan version of the Mini Mental State Examination. Score ranges 0-30, with higher score indicating better cognitive function.

  6. Cognitive function

    Time frame: 12th month following hospital discharge

    Cognitive function following hip-fracture surgery will be assessed using the Taiwan version of the Mini Mental State Examination. Score ranges 0-30, with higher score indicating better cognitive function.

  7. Cognitive function

    Time frame: 18th month following hospital discharge

    Cognitive function following hip-fracture surgery will be assessed using the Taiwan version of the Mini Mental State Examination. Score ranges 0-30, with higher score indicating better cognitive function.

  8. Cognitive function

    Time frame: 24th month following hospital discharge

    Cognitive function following hip-fracture surgery will be assessed using the Taiwan version of the Mini Mental State Examination. Score ranges 0-30, with higher score indicating better cognitive function.

  9. Depressive symptoms

    Time frame: 1st month following hospital discharge

    Patients' depressive symptoms will be evaluated using the 15-item Geriatric Depression Scale, short form (GDS-SF). Score range 0-15, with higher score indicating higher depressive symptoms.

  10. Depressive symptoms

    Time frame: 3rd month following hospital discharge

    Patients' depressive symptoms will be evaluated using the 15-item Geriatric Depression Scale, short form (GDS-SF). Score range 0-15, with higher score indicating higher depressive symptoms.

  11. Depressive symptoms

    Time frame: 6th month following hospital discharge

    Patients' depressive symptoms will be evaluated using the 15-item Geriatric Depression Scale, short form (GDS-SF). Score range 0-15, with higher score indicating higher depressive symptoms.

  12. Depressive symptoms

    Time frame: 12th month following hospital discharge

    Patients' depressive symptoms will be evaluated using the 15-item Geriatric Depression Scale, short form (GDS-SF). Score range 0-15, with higher score indicating higher depressive symptoms.

  13. Depressive symptoms

    Time frame: 18th month following hospital discharge

    Patients' depressive symptoms will be evaluated using the 15-item Geriatric Depression Scale, short form (GDS-SF). Score range 0-15, with higher score indicating higher depressive symptoms.

  14. Depressive symptoms

    Time frame: 24th month following hospital discharge

    Patients' depressive symptoms will be evaluated using the 15-item Geriatric Depression Scale, short form (GDS-SF). Score range 0-15, with higher score indicating higher depressive symptoms.

  15. Nutritional Status

    Time frame: 1st month following hospital discharge

    The 18-item Mini Nutritional Assessment (MNA). Score range 0-30, with higher score indicating better nutritioanl status.

  16. Nutritional Status

    Time frame: 3rd month following hospital discharge

    The 18-item Mini Nutritional Assessment (MNA). Score range 0-30, with higher score indicating better nutritioanl status.

  17. Nutritional Status

    Time frame: 6th month following hospital discharge

    The 18-item Mini Nutritional Assessment (MNA). Score range 0-30, with higher score indicating better nutritioanl status.

  18. Nutritional Status

    Time frame: 12th month following hospital discharge

    The 18-item Mini Nutritional Assessment (MNA). Score range 0-30, with higher score indicating better nutritioanl status.

  19. Nutritional Status

    Time frame: 18th month following hospital discharge

    The 18-item Mini Nutritional Assessment (MNA). Score range 0-30, with higher score indicating better nutritioanl status.

  20. Nutritional Status

    Time frame: 24th month following hospital discharge

    The 18-item Mini Nutritional Assessment (MNA). Score range 0-30, with higher score indicating better nutritioanl status.

  21. Health-Related Quality of Life (HRQoL)

    Time frame: 1st month following hospital discharge

    Taiwan version of the 36-item Short Form Survey (SF-36). Score range 0-100, with higher score indicating better health outcomes.

  22. Health-Related Quality of Life (HRQoL)

    Time frame: 3rd month following hospital discharge

    Taiwan version of the 36-item Short Form Survey (SF-36). Score range 0-100, with higher score indicating better health outcomes.

  23. Health-Related Quality of Life (HRQoL)

    Time frame: 6th month following hospital discharge

    Taiwan version of the 36-item Short Form Survey (SF-36). Score range 0-100, with higher score indicating better health outcomes.

  24. Health-Related Quality of Life (HRQoL)

    Time frame: 12th month following hospital discharge

    Taiwan version of the 36-item Short Form Survey (SF-36). Score range 0-100, with higher score indicating better health outcomes.

  25. Health-Related Quality of Life (HRQoL)

    Time frame: 18th month following hospital discharge

    Taiwan version of the 36-item Short Form Survey (SF-36). Score range 0-100, with higher score indicating better health outcomes.

  26. Health-Related Quality of Life (HRQoL)

    Time frame: 24th month following hospital discharge

    Taiwan version of the 36-item Short Form Survey (SF-36). Score range 0-100, with higher score indicating better health outcomes.

  27. number of visits to emergency department

    Time frame: 3rd month following hospital discharge

    collected by assessor asking family members

  28. number of visits to emergency department

    Time frame: 6th month following hospital discharge

    collected by assessor asking family members

  29. number of visits to emergency department

    Time frame: 12th month following hospital discharge

    collected by assessor asking family members

  30. number of visits to emergency department

    Time frame: 18th month following hospital discharge

    collected by assessor asking family members

  31. number of visits to emergency department

    Time frame: 24th month following hospital discharge

    collected by assessor asking family members

  32. number of hospital readmission

    Time frame: 3rd month following hospital discharge

    collected by assessor by asking family members

  33. number of hospital readmission

    Time frame: 6th month following hospital discharge

    collected by assessor by asking family members

  34. number of hospital readmission

    Time frame: 12 month following hospital discharge

    collected by assessor by asking family members

  35. number of hospital readmission

    Time frame: 18th month following hospital discharge

    collected by assessor by asking family members

  36. number of hospital readmission

    Time frame: 24 month following hospital discharge

    collected by assessor by asking family members

Study contacts

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

Jersey Liang, PhD

CONTACT

[email protected]

Yea-Ing Shyu, PhD

CONTACT

[email protected]

+886978697460

Sponsors and collaborators

Lead sponsor

Chang Gung Memorial Hospital

Other

Collaborators

  • Chang Gung University
  • National Health Research Institutes, Taiwan

Registry information

Official study title

Precision Care for Older Persons With Hip Fractures

Important dates

Study start
2026
Primary completion
2030
Study completion
2030
First posted
Feb 19, 2026
Registry last updated
Feb 19, 2026

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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