Leland Medical Clinic Patient-Centered Medical Chronic Disease Home Visitation Pilot
试验速览
- 阶段
- 不适用
- 发起方
- 入组人数
- 150
- 试验地点
- 2
- 主要终点
- Changes in HbA1C values
研究概览
简要总结
This pilot program will assess whether an enhanced PCMH model with more intensive management and intervention can improve chronic disease patient outcomes, improve healthcare delivery, and reduce healthcare costs. Participants in this program are current patients at Leland Medical Clinic and are either enrolled, or eligible to enroll, in Mississippi's Medicaid program. This pilot program will test the effectiveness of high-quality interventions comprising of: (1) an educational intervention focusing on chronic disease management and (2) home visits by a trained community outreach worker.
This pilot program will evaluate both process measures and outcome measures. Examples of process measures include, but are not limited to, the number of patients enrolled in each intervention group, the number of educational classes attended by a unique patient, and the number of home visits a unique patient receives. Examples of outcomes measures include, but are not limited to, change in patient HbA1C levels, change in patient LDL/HDL levels, change in patient blood pressure (systolic and diastolic) levels, and a comparison of patient cost data (total expenditure, expenditures by other major categories like hospital, pharmacy, etc.) After baseline measurements, patient clinical values will be acquired every 3 months for the duration of their engagement.
This pilot project has three specific goals:
Goal 1: Improve healthcare delivery for chronic disease patients enrolled in Mississippi Medicaid.
Goal 2: Improve clinical outcomes for chronic disease patients enrolled in Mississippi Medicaid.
Goal 3: Reduce Mississippi Medicaid costs for chronic disease patients enrolled in this pilot program.
详细描述
Research Protocol including:
Research procedures:
The aim of this research project is to test whether an enhanced PCMH model with more intensive management and intervention can improve patient outcomes and reduce costs related to chronic disease conditions.
Project eligibility:
- Leland Medical Clinic patient
- Ages 18+
- Medicaid beneficiaries or are Medicaid eligible
- Diagnosis of diabetes and at least one other chronic condition, and an A1c value of 7.5 or above
研究设计
- 研究类型
- Interventional
- 分配方式
- 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 —（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •Leland Medical Clinic (LMC) patients
- •Medicaid beneficiary or no insurance
- •Active diabetes diagnosis
- •Diagnosis of at least one other chronic condition (COPD, Hypertension, chronic kidney disease, CHF
- •Baseline HbA1c 7.0 or above.
排除标准
- •Patients with active psychoses will not be eligible.
结局指标
主要结局
Changes in HbA1C values
时间窗: Six months and three months before enrollment, at enrollment, three and six months follow-ups
Data recorded in electronic health records system
次要结局
- ED visits(Baseline and six-month follow-up)
- Patient Engagement and Activation(At enrollment in intervention, six month follow-up)
- Physical Activity(At enrollment in intervention, six month follow-up)
- Changes in blood pressure values(Six months and three months before enrollment, at enrollment, three and six months follow-ups)
- Hospitalizations(Baseline and six-month follow-up)
- Changes in LDL values(Six months and three months before enrollment, at enrollment, three and six months follow-ups)
- Diet(At enrollment in intervention, six month follow-up)
- Total medical costs(End of enrollment in intervention and six month follow-up)
- Medication adherence(At enrollment in intervention, six month follow-up)