This trial is active, not recruiting.

Condition chronic disease
Treatment nurse-physician comprehensive care
Sponsor Meir Medical Center
Collaborator Israel National Institute for Health Policy and Health Services Research
Start date March 2013
End date March 2017
Trial size 1800 participants
Trial identifier NCT01811173, CCMAP


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.

United States No locations recruiting
Other Countries No locations recruiting

Study Design

Allocation non-randomized
Endpoint classification efficacy study
Intervention model parallel assignment
Masking open label
Primary purpose health services research
Comprehensive self management support and care coordination by a nurse-primary care physician team
nurse-physician comprehensive care
Components of the intervention include: Complete assessment of the patient's and family's needs conducted by the nurse. Comprehensive treatment program developed by the nurse and in consultation with the primary care physician. "Multimorbid care plan" integrating all care aspects. "Action Plan" for patients, supporting self management Proactive monitoring according to the plan.
(No Intervention)
Patients will receive usual primary care and asked to complete questionnaires on four time points throughout the study
(No Intervention)
Patients will receive usual primary care.

Primary Outcomes

Percent change in admissions for ambulatory care sensetive conditions
time frame: At enrollment and within 12 months and 24 months after enrollment

Secondary Outcomes

Emergency 30-day readmissions
time frame: 30 days post an index admission

Eligibility Criteria

Male or female participants from 18 years up to 95 years old.

Inclusion Criteria: - ACG system high risk probabilty score - 4% Highest Risk Score - Age 18 and older - 2 or more chronic conditions Exclusion Criteria: - 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

Additional Information

Official title The Clalit Comprehensive-Care for Multimorbid Adults Project
Principal investigator Ran D Balicer, PhD
Description 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: 1. Comprehensive assessment of the patient's and family's needs 2. Coordinated care plan based on integrated care guides 3. "Multimorbid Action Plan" for patients 4. All-inclussive patient centered care and caregiver support 5. 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.
Trial information was received from ClinicalTrials.gov and was last updated in April 2015.
Information provided to ClinicalTrials.gov by Meir Medical Center.