Specialty: Primary Care, Primary sub-specialty: Primary care
Conditions
Interventions
This is a six practice cluster randomised controlled mixed-methods feasibility trial, to test the feasibility of goal-setting as part of the care planning process in 60 patients with multimorbidity an
Sponsors
NHS South Norfolk CCG
Eligibility
Sex/Gender
All
Inclusion criteria
Inclusion criteria: Inclusion criteria for practices: 1. In the ‘Avoiding Unplanned Admissions Enhanced Service (ES): proactive case finding and care review for vulnerable people for general practice’ (over 90% of practices in England), or similarly using risk stratification to identify patients at high risk of unplanned admission 2. At least one GCP trained GP (to be site Principal Investigator) and one GCP trained nurse for data collection 3. GPs must be available to attend pre-arranged goal-setting training in the event that their practice is randomised to the intervention group Inclusion criteria for patients: 1. Age 18 or over 2. In the top 2% for risk of unplanned admission, e.g. on the practice register for ‘Avoiding Unplanned Admissions’ ES or similar, and so eligible for a new or review case planning consultation during the data collection period 3. Diagnosed with at least 2 of 40 morbidities in Barnett’s analysis of multimorbidity, which includes diseases in the Quality and Outcomes Framework
Exclusion criteria
Exclusion criteria: Exclusion criteria for practices: 1. Single handed practice Exclusion criteria for patients: 1. Not able to participate in goal-setting in GP’s professional opinion (e.g. advanced dementia or acute psychosis) 2. Received care planning consultation in previous three months 3. Require translation services to communicate verbally
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| 1. Recruitment rate (practice level) is measured as the number of general practices that consent to participate at 3 months 2. Recruitment rate (patient level) is measured as the number of eligible patients that consent to participate in the study by 6 months 3. Quality of life is measured using the EQ-5D questionnaire and the ICECAP-O questionnaire at baseline and 6 months 4. GAS-Light goal achievement is measured for intervention group patients after the second care plan consultation 5. Patient involvement with care planning and goal-setting is measured using the Dyadic OPTION and CollaboRATE scales after the initial care plan consultation, and the Patient Assessment of Care for Chronic Conditions (PACIC) 20-item questionnaire at baseline and 6 months 6. Cognition is measured using the General Practitioner Assessment of Cognition (GPCOG) Score at baseline and 6 months 7. Healthcare resource use is measured by the number of hospital admissions, A&E and outpatient contacts, and primary care staff contacts at 6 months, by reviewing patient notes 8. Number and type of prescribed medications will be measured at 6 months, by reviewing patient notes 9. Mortality will be measured at 6 months by reviewing patient notes | — |
Secondary
| Measure | Time frame |
|---|---|
| No secondary outcome measures | — |
Countries
United Kingdom
Contacts
Public ContactNick Steel
Outcome results
None listed