Chronic Disease
Conditions
Brief summary
Controlled and Randomized Clinical trial with 3 parallel groups (intervention group with a health platform NOMHADchronic, phone-based care group, usual care group) developed in the Valencia La Fe Health Department. 495 high-complexity chronic patients will be included according to a combined recruitment based on a risk predictive model plus clinical opinion. Patients will be followed-up during 12 months in order to evaluate health-related quality of life, mortality, health consumption, health direct cost and treatment satisfaction.
Interventions
Intervention group with a health Platform NOMHADchronic
Sponsors
Study design
Eligibility
Inclusion criteria
* Age ≥18 years old. * High complexity: according to a combined criteria a) predictive model of Valencia La Fe Health department for hospital resources consumption in next 12 months (probability \>95%) and b) risk confirmation by a clinical team with experience on chronic patients management. * Participants that accept to participate in the study by the informed consent signature * Participants that don't meet any of the
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Health Related Quality of Life according to EuroQoL (5 questions, 3 levels) | 12 months |
Secondary
| Measure | Time frame |
|---|---|
| Health Related Quality of Life according to EuroQoL EVA | 12 months |
| Mortality | 12 months |
| Number of emergencies room visits | 12 months |
| Number of non-planned hospitalizations | 12 months |
| Change from Baseline HRQL | 12 months |
| Health resources consumption according to total number of ER visits and non-planned hospitalizations | 12 months |
| Health direct costs using health resources consumption and unitary cost for each resource. | 12 months |
| Treatment satisfaction using an ad hoc Likert questionnaire | 12 months |
| Adverse events causing ER visits or non-planned hospitalization | continous |