Comprehensive-Care for Multimorbid Adults Effectiveness Study
This trial is active, not recruiting.
|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|
|Ashdod, Israel||Ashdod A||no longer recruiting|
|Ashdod, Israel||Ashdod D||no longer recruiting|
|Azur, Israel||Azur||no longer recruiting|
|Bat YAm, Israel||Arlozorov||no longer recruiting|
|Bat Yam, Israel||Hashikma||no longer recruiting|
|Bat Yam, Israel||Ramat Yosef||no longer recruiting|
|Bat Yam, Israel||Sokolov||no longer recruiting|
|Hulon, Israel||Halutz||no longer recruiting|
|Hulon, Israel||Shikun Ammi||no longer recruiting|
|Lod, Israel||Lod Center||no longer recruiting|
|Ramla, Israel||Ramla Ztafon||no longer recruiting|
|Rishon Lezion, Israel||Balfur||no longer recruiting|
|Rishon Lezion, Israel||Migdal HaIr||no longer recruiting|
|Endpoint classification||efficacy study|
|Intervention model||parallel assignment|
|Primary purpose||health services research|
Percent change in admissions for ambulatory care sensetive conditions
time frame: At enrollment and within 12 months and 24 months after enrollment
Emergency 30-day readmissions
time frame: 30 days post an index admission
Male or female participants from 18 years up to 95 years old.
- ACG system high risk probabilty score - 4% Highest Risk Score
- Age 18 and older
- 2 or more chronic conditions
- 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
|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.|
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