Primary Care Based Integrated Community Care Team Intervention

Recruitment & Eligibility

Status: TERMINATED

Sex: All

Target Recruitment: 41

Inclusion Criteria

Living within the designated geographical zone
50 years and above
Satisfy the Medical Criteria below:
1. Diabetes with HbA1c ≥ 9% (within past 6 months), and
2. At least 1 complication
  1. chronic kidney impairment stage 3 and above, or diabetes overt nephropathy,
  2. ischaemic heart disease, or congestive cardiac failure,
  3. peripheral arterial disease, or diabetes foot/ diabetes foot-related complications,
  4. diabetic retinopathy/ treatment for retinopathy, and
  5. stroke, or transient ischaemic attack
Satisfy at least 2 conditions in the psycho-social, functional or activation domain of which 1 criteria must be from the psycho-social domain:
1. Psycho-social issues
  
  a. Lack of care giver support i. No care-giver (when indicated) ii. Care-giver skills gap/ stress iii. Inability of copy when patient is the care-giver b. Difficult relationships (family/ workplace/ social network) c. Social isolation/ lack of social connectivity i. Lives alone ii. Lack of social network support d. Financial i. Financial difficulty/ insecurity ii. Housing/ shelter issues iii. Poor money management
2. Functional
  1. Clinical Frailty Score ≥ 4, requiring help in instrumental activities of daily living (iADL)
  2. Requires assistance in ADL or iADL
3. Activation a. Lack of ability to manage health - disengaged or overwhelmed i. Anxiety or disease-related distress ii. Confusion or lack of understanding of care plans iii. Non-adherence to medications/ follow up
Patient gives consent to participate
For patients who may be seeing a Primary Care Physician (PCP) outside of the polyclinic for chronic disease management and where the PCP has indicated consent to co-manage the patient with the PACE-It team including the polyclinic physician
Patient must be willing to receive care in the polyclinic

Exclusion Criteria

Patients who are on follow up with Primary Care Physicians or General Practitioners elsewhere for management of their chronic conditions and they do not consent to co-managing patient with the PACE-It team
Patients who have severe cognitive impairment, depression or psychiatric conditions that interfere with the ability to engage with the healthcare team
Patients who are (i) not community ambulant or (ii) bed bound
Patients with terminal illness
Patients who have are in other programs or research studies
Patients who do not give consent

Study & Design

Study Type: INTERVENTIONAL

Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Intervention arm	PACE-It mobile application	Providers use PACE-It mobile application as a care co-ordination platform

Primary Outcome Measures

Name	Time	Method
HbA1c	1 year	Glycemic control

Secondary Outcome Measures

Name	Time	Method
Provider's satisfaction	2 years	Qualitative survey and interview
Blood pressure	1 year	Systolic and diastolic blood pressure (mmHg)
LDL-cholesterol	1 year	Low-density lipoprotein cholesterol
Cost-effectiveness	2 years	Cost-effectiveness of care model
Patient activation measure (PAM)	1 year	Patient's activation levels
Medication adherence measure (MARS-5)	1 year	Patient's adherence to medication
EQ-5D-5L	1 year	Quality of life
Patient satisfaction	1 year	Qualitative survey and interview
Implementation of care model	2 years	Factors affecting implementation of care model

Primary Care Based Integrated Community Care Team Intervention

Recruitment & Eligibility

Study & Design

Trial Locations

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