Complex bio-psycho-social care needs
Conditions
Interventions
Group 1: NAVIGATION
NAVIGATION is a six-month integrated care model for the care of people with complex bio-psychosocial needs. The model is flexible within this period. The necessary measures are ut
Sponsors
Charité - Universitätsmedizin Berlin, Institut für Allgemeinmedizin
Eligibility
Sex/Gender
All
Age
18 Years to No maximum
Inclusion criteria
Inclusion criteria: Intervention group (individual): Patients capable of giving consent who live in the service area of the respective health centre, have at least one chronic illness and at least one social problem and are covered by statutory health insurance. Intervention group at social area level, control group: Patients capable of giving consent who live in the health centre's service area (intervention group at social area level) or live in neighbourhoods with a similar population composition (pre-selection, control group)
Exclusion criteria
Exclusion criteria: Patients under guardianship in the area of health care
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Patient activation measured at 6 months with the validated PAM13-D questionnaire | — |
Secondary
| Measure | Time frame |
|---|---|
| Patient Reported Outcome Measures measured at basline, at 6 and 18 months (PROMs): Patient activation at 18 months (PAM13-D) Experienced Patient-Centeredness Questionnaire (EPAT-16) General life satisfaction (L-1) Health-related quality of life (EQ-5D-5L) Navigational health literacy (navigational dimension of the HLS-EU-Q16) Well-being (ICECAP-A) Loneliness (De Jong Gierveld Loneliness Scale) Subjective state of health (MEHM) Self-efficacy (ASKU) Care needs (individual intervention group) Satisfaction with the intervention (individual intervention group) Goal-based endpoint (individual intervention group) Health economic endpoints: Utilisation of components of the new form of care a) Care services: Extended initial anamnesis for new patients, incl. assessment of bio-psycho-social care needs; interprofessional interim and final consultation with patients as part of the GP-CHN tandem; social counselling; psychological counselling; nursing consultation; telephone checks; group services b) Coordination services: Interprofessional case presentation at the start of care, interprofessional case conferences in the further course; interprofessional team meetings; coordinated exchange of information with the public health service Utilisation of statutory health insurance services as part of standard care (outpatient, inpatient, rehabilitation, medication, remedies, nursing care) a) Outpatient-sensitive hospital cases (ASK) b) Days of incapacity for work c) Care costs from a health insurance perspective Utilisation of benefits from pension insurance providers (DRV) a) Reduced earning capacity pension b) Prevention benefits c) Rehabilitation measures c) Care costs from the perspective of the DRV Combination of cost results in terms of cost-effectiveness | — |
Countries
Germany
Contacts
Public ContactHendrik Napierala
Charité – Universitätsmedizin Berlin, Institut für Allgemeinmedizin
Outcome results
None listed