The Clalit Comprehensive-Care for Multimorbid Adults Project
试验速览
- 阶段
- 不适用
- 入组人数
- 1,800
- 试验地点
- 13
- 主要终点
- Percent change in admissions for ambulatory care sensetive conditions
研究概览
简要总结
This study is intended to examine whether directed care of a nurse working jointly with the patient's primary care physician, including a comprehensive assessment, creation of a tailored care plan, proactive follow-up, self management support and caregiver support and care coordination, can reduce hospital admissions for patients with multiple chronic conditions.
详细描述
Patients with multi-morbidities pose a significant challenge for healthcare organizations because they require continuity of care among a wide range of long-term therapeutic paradigms for many different types of diseases. The current study is based on a treatment model entailing a nurse-primary care physician team to provide care for patients with multiple morbidities.
Patients in the intervention group who agreed and signed the consent form to participate in the study will receive treatment by the physician - nurse team in accordance with the components of the Clalit's Comprehensive Care for Mutlimorbid Adults Project model. Components of the intervention include:
- Comprehensive assessment of the patient's and family's needs
- Coordinated care plan based on integrated care guides
- "Multimorbid Action Plan" for patients
- All-inclussive patient centered care and caregiver support
- Proactive monitoring according to the plan.
Patients in the control groups will receive usual care in their primary care clinics. The Usual Care Survey control group will complete study questionnaires at 6, 12 and 24 months after enrollement.
The Usual Care Blinded group will be assessed only retrospectively based on deidentified information from Clalit's admistrative databases.
研究设计
- 研究类型
- Interventional
- 分配方式
- Non Randomized
- 干预模型
- Parallel
- 主要目的
- Health Services Research
- 盲法
- None
入排标准
- 年龄范围
- 18 Years 至 95 Years（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •ACG system high risk probabilty score - 4% Highest Risk Score
- •Age 18 and older
- •2 or more chronic conditions
排除标准
- •Patients already included in a controlled disease management program (e.g., COPD disease management and telehealth).
- •Participation in any medical research.
- •Confined to bed.
- •Inpatient nursing care, nursing homes.
- •Kidney, liver or heart transplant patients.
- •Active (receipt of oncology chemotherapy , radiotherapy or other oncology treatment during the past 3 years).
- •Dialysis patients.
- •Clalit Healthcare Services employees.
- •Patients with major active mental illness, such as schizophrenia.
- •Cognitive failure.
- •Non Hebrew speaking patients without Hebrew speaking primary informal caregiver.
- •Bedridden patients
- •Housebound patients
结局指标
主要结局
Percent change in admissions for ambulatory care sensetive conditions
时间窗: At enrollment and within 12 months and 24 months after enrollment
Ambulatory Care Sensitive Conditions will be defined by ICD-9 codes, based on the classification published by: Ansari, Barbetti, Carson, Auckland, \& Cicuttini, 2003 (adapted from Weissman JS, Gatsonis C, Epstein AM ,1992; Millman M, ed. 1993)
次要结局
- Emergency 30-day readmissions(30 days post an index admission)