Impact of a Proactive and Integrated Health Intervention Between Different Assistance Levels Over Some Indicators in the Care of Chronic Complex Patient (CCP)
试验速览
- 阶段
- 不适用
- 状态
- 已完成
- 发起方
- 入组人数
- 28
- 试验地点
- 2
- 主要终点
- Pre-post change in days of Hospital stay from baseline to 16 weeks.
研究概览
简要总结
The aim of this study is to assess the effectiveness of proactive and integrated healthcare program for chronic complex patients (CCP). This program are based in coordination the primary level of attention with and speciality level. The objective is reducing hospital readmissions and know the benefit in total cost of care in 4 month before and 4 after intervention.
详细描述
Quasi-experimental study with single-arm (pre-post study design without control group). The investigators checking pre and post intervention the effectiveness of a healthcare program for CCP. The interventions consist:
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- Help the nurse in the hospital to carry out the care plans and the continuity care report.
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- Refer patients to the social workers.
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- Collaborate with the social worker to refer to centers of media, long stay and reference hospital.
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- Ensure the follow-up appointments for the CCP.
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- Make proactive calls to the CCP and/or their caregiver after discharge
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- Plan the hospital discharge 48 hours in advance, so that the family and the patient can be organized.
The investigator analysed if with this program, the CCP reducing hospital readmission and reducing the Hospital expenditure.
研究设计
- 研究类型
- Interventional
- 分配方式
- Na
- 干预模型
- Single Group
- 主要目的
- Prevention
- 盲法
- None
入排标准
- 年龄范围
- 75 Years 至 —（Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •Patient ≥ 75 years.
- •Having attended 5 or more emergency visits or having had more than 3 hospital admissions in the last 12 months.
- •Identified with social risk alert.
排除标准
- •Participate in other health programs (AHT, diabetes mellitus,...).
- •Terminal patient.
结局指标
主要结局
Pre-post change in days of Hospital stay from baseline to 16 weeks.
时间窗: Baseline and 16 weeks.
The same group of patients are analyzed the days of hospital stay at the end of 16 weeks of follow-up pre intervention (baseline) and 16 week after the intervention.
次要结局
- Number of primary care visits for CCP change from baseline to 16 weeks.(Baseline and 16 weeks.)
- Number of urgency visits for CCP change from baseline to 16 weeks.(Baseline and 16 weeks.)
- Number of hospital readmissions visits for CCP change from baseline to 16 weeks.(Baseline and 16 weeks.)
研究者
María José del Olmo Rubio
Principal investigator
Hospital Universitario 12 de Octubre