Goal-setting in care planning for people with multimorbidity

Not Applicable

Completed

• Conditions: Specialty: Primary Care, Primary sub-specialty: Primary care; UKCRC code/ Disease: Other/ General symptoms and signs; Not Applicable; Care planning

• Registration Number: ISRCTN13248305
• Lead Sponsor: HS South Norfolk CCG

Brief Summary

2019 results in: https://www.ncbi.nlm.nih.gov/pubmed/31164362 (added 05/07/2019) 2019 qualitative analysis results in: https://www.ncbi.nlm.nih.gov/pubmed/31160370 (added 05/07/2019)

Detailed Description

Not available

Study Timeline

• Results First Posted: 1900-01-01
• Study Start: 2016-12-21
• Study Completion: 2018-07-31
• Last Update Posted: 29 July 2019

Recruitment & Eligibility

• Status: Completed
• Sex: All
• Target Recruitment: 52

Inclusion Criteria

Inclusion criteria for practices:
1. In the ‘Avoiding Unplanned Admissions Enhanced Service (ES): proactive case finding and care review for vulnerable people for general practice’ (over 90% of practices in England), or similarly using risk stratification to identify patients at high risk of unplanned admission
2. At least one GCP trained GP (to be site Principal Investigator) and one GCP trained nurse for data collection
3. GPs must be available to attend pre-arranged goal-setting training in the event that their practice is randomised to the intervention group

Inclusion criteria for patients:
1. Age 18 or over
2. In the top 2% for risk of unplanned admission, e.g. on the practice register for ‘Avoiding Unplanned Admissions’ ES or similar, and so eligible for a new or review case planning consultation during the data collection period
3. Diagnosed with at least 2 of 40 morbidities in Barnett’s analysis of multimorbidity, which includes diseases in the Quality and Outcomes Framework

Exclusion Criteria

Exclusion criteria for practices:
1. Single handed practice

Exclusion criteria for patients:
1. Not able to participate in goal-setting in GP’s professional opinion (e.g. advanced dementia or acute psychosis)
2. Received care planning consultation in previous three months
3. Require translation services to communicate verbally

Study & Design

• Study Type: Interventional
• Study Design: Not specified