This paper has been accepted and is currently in production.
It will appear shortly on 10.2196/91524
The final accepted version (not copyedited yet) is in this tab.
Warning: This is an author submission that is not peer-reviewed or edited. Preprints - unless they show as "accepted" - should not be relied on to guide clinical practice or health-related behavior and should not be reported in news media as established information.
ASSETs for Aging in Place: Quantitative Evaluation of Technology-Supported Interprofessional Care Coordination After Nursing Home Discharge
ABSTRACT
Background:
Older and disabled adults face ongoing barriers to aging in place after nursing home discharge, particularly following the end of time-limited transition programs. Sustained care coordination and early detection of health and functional changes remain limited, especially in rural and under-resourced communities.
Objective:
To examine changes in quality of life (QoL), function, and cognition over 12 months among older adults enrolled in the ASSETs for Aging in Place (AIP) program and to assess the feasibility of technology-enabled interdisciplinary care coordination.
Methods:
This quantitative, descriptive study used repeated measures over 12 months among older and disabled adults one-year post-discharge from Missouri’s Show-Me Home program. An interdisciplinary team (registered nurse, occupational therapist, and social worker) provided remote care coordination supported by open-source smart home sensors, consumer-grade wearable devices, and telehealth. Outcomes were assessed quarterly using the interRAI Home Care assessment and the Money Follows the Person Quality of Life survey.
Results:
Nineteen participants were included. Functional status, cognitive performance, and instrumental activities of daily living remained stable over time. Quality of life measures were consistently high across domains, with no significant declines observed. Reports of unmet medical care needs decreased across follow-up. Sensor and wearable data supported remote monitoring, early identification of changes in activity patterns, and timely care coordination.
Conclusions:
This study demonstrates the feasibility of a digital health–enabled, interdisciplinary care coordination program using cost-feasible open-source and consumer-grade technologies. Preliminary findings suggest maintenance of function and quality of life among participants. Larger-scale implementation is needed to further evaluate effectiveness and refine data-driven care coordination workflows for underserved populations.
Citation
Request queued. Please wait while the file is being generated. It may take some time.
Copyright
© The authors. All rights reserved. This is a privileged document currently under peer-review/community review (or an accepted/rejected manuscript). Authors have provided JMIR Publications with an exclusive license to publish this preprint on it's website for review and ahead-of-print citation purposes only. While the final peer-reviewed paper may be licensed under a cc-by license on publication, at this stage authors and publisher expressively prohibit redistribution of this draft paper other than for review purposes.