None listed
Conditions
Brief summary
The FNQHAT is a pragmatic randomised controlled trial which aims to reduce avoidable hospitalisations and Emergency Department visits for ‘frequent flyer’ adults with diabetes, cardiovascular disease, renal disease and chronic obstructive pulmonary disease. The primary objective is to improve primary health care-level chronic care processes (such as benchmarking, care planning and guideline concordance) and also patient outcomes (such as clinical indicator change, avoidable hospitalisations and ED visits and disease progression). FNQHAT is funded through the Queensland Department of Health’s Health Innovation Fund (HIF) as a joint project between the Cairns and Hinterland Hospital and Health Service (CHHHS) and James Cook University (JCU) Centre for Chronic Disease Prevention in Cairns. The CHHHS Sponsor is Dr Neil Beaton and the JCU lead is Professor Robyn McDermott. The study aims to recruit up to 530 “frequent flyers” over a 12-24-month period. People with chronic disease who have been identified as visiting one of the three participating hospitals in FNQ (Cairns Hospital, Innisfail Hospital and Mareeba Hospital) will be recruited. At least 25% of participants are expected to be Aboriginal or Torres Strait Islander and therefore the project will be undertaken in collaboration with the relevant Aboriginal Medical Services, WuChopperen in Cairns, Mamu in Innisfail and Mulungu in Mareeba. The study will compare usual best practice for managing chronic disease in the community (referral to GP) with close case management of clients in addition to usual best practice care. The study will also be trialling software which can connect to both the hospital and primary health care information systems. This will enable the use of a single patient record by the whole care team and will assist in communication between different health services, generating patient management plans and reporting on clinical care processes and measures. A Clinical Governance Group will also be established to oversee provision of care provided to participants and a Data Safety and Monitoring Group will monitor data quality and adverse events and to ensure participant safety throughout the study. Potential patients for the trial will be identified from EDIS and HBCIS data in participating hospitals according to the following eligibility criteria: (1) Had 8 or more presentations to the ED and/or hospitalisations in the previous 12 months for a potentially preventable hospitalisation (2) Aged 18-75 and reside within the area of a participating site. (3) Have at least one chronic condition identified (diabetes, cardiovascular disease, renal disease or chronic obstructive pulmonary disease).
Interventions
Close case management in the community in addition to usual best practice care.
Consenting eligible participants will have a full baseline assessment performed at Visit 1 and referral to their GP, including a request for a formal care plan. Those randomised to the intervention group (case management) will additionally be allocated to a care co-ordinator who resides in their community.
A key feature of the intervention will be the deployment of an integrated care planning and reporting tool whic
Close case management in the community in addition to usual best practice care. Consenting eligible participants will have a full baseline assessment performed at Visit 1 and referral to their GP, including a request for a formal care plan. Those randomised to the intervention group (case management) will additionally be allocated to a care co-ordinator who resides in their community. A key feature of the intervention will be the deployment of an integrated care planning and reporting tool which is attached to the Primary Health Care patient management system, and which can be utilised across the care team, including the Emergency Department, hospital inpatient system, and other community-based care providers e.g. allied health, Indigenous health workers where relevant. In summary, the intervention group will receive: (1) A dedicated case manager (Registered Nurse) who will initially map the social and health needs of the client. The case manager will work closely with the participant including face-to-face contact in the clinic, home visits and via telephone. The contact will be provided on an 'as needed' basis over the entire period of the study (approximately 1-2 years). (2) A “medical home” – referral to a Primary Care service which will provide integrated care and serve as the focus of health care planning and delivery for the client. (3) The installation, and training by the whole team in the use of, software which will generate an integrated General Physician Management Plan (GPMP) and Team Care Arrangements (TCA), which will be utilised by all providers including allied health and hospital-based services, and which will generate periodic reports for the service providers. (4) Access to self-management health care coaching for clients who accept this. (5) For Indigenous clients, a trained health worker will also be assigned to assist with identified issues, and also to mentor the case managers in cultural aspects of care delivery and self-management.
Sponsors
Cairns & Hinterland Hospital and Health Service
Study design
Allocation
Randomised controlled trial
Primary purpose
Treatment
Eligibility
Sex/Gender
All
Age
18 Years to 75 Years
Healthy volunteers
No
Inclusion criteria
(1) 8 or more presentations to the ED and/or hospitalisations in the previous 12 months for a Potentially Preventable Hospitalisation (PPH) condition; (2) aged 18-75; (3) have at least one chronic condition (diabetes, cardiovascular disease, renal disease or chronic obstructive pulmonary disease); and (4) reside within the area of a participating site.
Exclusion criteria
(1) people not permanently residing in the study area; (2) people on renal dialysis; (3) people with major mental health problems such as psychosis or with substance misuse problems; (4) people with a diagnosis of cancer; (5) people with dementia or other condition which will significantly reduce the ability to consent fully to undertake the program.
Outcome results
None listed