Chronic Disease
Conditions
Keywords
multimorbidity, primary care, physician - nurse team, proactive monitoring, support for self-care, primary caregiver
Brief summary
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.
Detailed 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.
Interventions
OTHERNurse-physician comprehensive care
Components of the intervention include: 1. Complete assessment of the patient's and family's needs conducted by the nurse. 2. Comprehensive treatment program developed by the nurse and in consultation with the primary care physician. 3. Multimorbid care plan integrating all care aspects. 4. Action Plan for patients, supporting self management 5. Proactive monitoring according to the plan.
Sponsors
Israel National Institute for Health Policy and Health Services Research
Meir Medical Center
Study design
Allocation
NON_RANDOMIZED
Intervention model
PARALLEL
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to 95 Years
Healthy volunteers
No
Inclusion criteria
* ACG system high risk probabilty score - 4% Highest Risk Score * Age 18 and older * 2 or more chronic conditions
Exclusion criteria
* 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
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Percent change in admissions for ambulatory care sensetive conditions | At enrollment and within 12 months and 24 months after enrollment | Ambulatory Care Sensitive Conditions will be defined by ICD-9 codes, based on the classification published by: Ansari, Barbetti, Carson, Auckland, & Cicuttini, 2003 (adapted from Weissman JS, Gatsonis C, Epstein AM ,1992; Millman M, ed. 1993) |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Emergency 30-day readmissions | 30 days post an index admission | Emergency readmissions are defined as an urgent (via the Emergency Room) admission of one night or longer, following an index admission that lasted 2 nights or longer, in the prior 30 days. |
Other
| Measure | Time frame | Description |
|---|---|---|
| Change in SF-12 Physical and Menal component scores | At enrollment and 6, 12, and 24 months after enrollment | Change in Physical and Menal Component scores of the SF-12 measure, as completed by patients through patient interviews |
Countries
Israel
Outcome results
None listed