The Community Primary Care Programme: Enhancing care of people with complex chronic conditions

The Efficacy of Complex Integrated Community Primary Care Programme in People with Complex Chronic Conditions

Status

Active, not recruiting

Phases

Phase 2

Study type

Observational

Source

ChiCTR

Registry ID

ChiCTR-OIC-16008477

Enrollment

Unknown

Registered

2016-05-09

Start date

2016-05-23

Completion date

Unknown

Last updated

2018-07-31

For informational purposes only — not medical advice. Sourced from public registries and may not reflect the latest updates. Terms

Conditions

people with complex chronic conditions

Interventions

Case series:Complex Integrated Community Primary Care Programme

Eligibility

Sex/Gender

All

Age

60 Years to No maximum

Inclusion criteria

Inclusion criteria: 1) Chinese; 2) Aged 60 or above; 3) With 2 or more long term chronic diseases; 4) Patient from the public and private primary care clinics with complex psychological and social needs (i.e. immigrants, single mothers, elderly who lives alone with multiple health problems etc.); 5) Service user from community non-government organizations (NGO) in the region with more than one chronic medical condition.

Exclusion criteria

Exclusion criteria: 1) Cognitive impairment with MMSE score less than 18; 2) Immobility. Confined to a bed or chair for > 22 hours per day; for at least 4 of the past 7days; 3) Lacking capacity of consent.

Design outcomes

Primary

Measure	Time frame
The change of EQ5D5L from baseline to the end of month 24;	—

Secondary

Measure	Time frame
Change of lifestyle (e.g. physical activities level, smoking, alcohol consumption);Change of health parameters (eg, blood pressure, pain assessment and body mass index (BMI),;Change of health service utilization pattern (having a family doctor, self-care, use of public primary care clinics (ie, the general outpatient clinic (GOPC)) and accident and emergency service);Change of psychosoical health (e.g. anxiety, depression, social support, loneliness level and meaningfulness in life),;Change of self care ability, cognitive assessment and habit of seeking health information;	—

Measure

Time frame

Change of lifestyle (e.g. physical activities level, smoking, alcohol consumption);Change of health parameters (eg, blood pressure, pain assessment and body mass index (BMI),;Change of health service utilization pattern (having a family doctor, self-care, use of public primary care clinics (ie, the general outpatient clinic (GOPC)) and accident and emergency service);Change of psychosoical health (e.g. anxiety, depression, social support, loneliness level and meaningfulness in life),;Change of self care ability, cognitive assessment and habit of seeking health information;

—

Countries

China

Contacts

Public ContactSamuel Yeung-shan WONG

The Chinese University of Hong Kong

yeungshanwong@cuhk.edu.hk+852 2252-8774

Outcome results

None listed

Source: ChiCTR (via WHO ICTRP) · Data processed: Feb 19, 2026