Chronic Disease Clinical Trial
Official title:
The Clalit Comprehensive-Care for Multimorbid Adults Project
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.
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.
;
Allocation: Non-Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Health Services Research
| Status | Clinical Trial | Phase | |
|---|---|---|---|
| Completed |
NCT03153644 -
Improving Contraceptive Care for Women With Medical Conditions
|
||
| Recruiting |
NCT06058754 -
Group-based [ADAPT] Versus One-to-one [Usual] Occupational Therapy (Go:OT Trial)
|
N/A | |
| Completed |
NCT04082585 -
Total Health Improvement Program Research Project
|
||
| Recruiting |
NCT05558085 -
Biomarker Cost-Benefit Analysis of EFNEP
|
N/A | |
| Completed |
NCT04037436 -
Functional Exercise and Nutrition Education Program for Older Adults
|
N/A | |
| Not yet recruiting |
NCT05622422 -
A Chronic Disease Self Care Management Pilot Study
|
N/A | |
| Not yet recruiting |
NCT06016101 -
Usefulness of the Medissimo Nurse Application for Supporting Medication Compliance in Elderly People With Chronic Polypathologies
|
||
| Not yet recruiting |
NCT04954209 -
Comparative Study in Long-term Commitment to Physical Activity After Two Different Resumption Programs
|
||
| Not yet recruiting |
NCT04090593 -
Chronic Disease Mobile Educational Experience
|
N/A | |
| Not yet recruiting |
NCT03628963 -
Optimizing Patient Usability Experience for Chronic Care
|
N/A | |
| Completed |
NCT02390570 -
Incorporating Patient Capacity Into the Clinical Landscape
|
N/A | |
| Completed |
NCT02072941 -
Preparing Spanish-speaking Older Adults for Advance Care Planning and Medical Decision Making (PREPARE)
|
N/A | |
| Completed |
NCT01933789 -
Improving Communication About Serious Illness
|
N/A | |
| Completed |
NCT02017262 -
Group Self-Management of Depression and Medical Illness
|
N/A | |
| Completed |
NCT02292940 -
Consumer Health IT Tools: Impact on Experience, Access, and Outcomes for Patients With Complex Chronic Conditions
|
||
| Terminated |
NCT02115971 -
Jumping Exercises Approach in Individuals With Chronic Ankle Instability
|
N/A | |
| Completed |
NCT02307929 -
Evaluation of Quality of Care - Nurse Allied Health Clinic Programme, HA
|
N/A | |
| Completed |
NCT01458184 -
Study of PhoneCare System to Treat Patients With Chronic Diseases
|
N/A | |
| Completed |
NCT00333710 -
Evaluating a Telehealth Treatment for Veterans With Hepatitis C and PTSD
|
N/A | |
| Completed |
NCT00380536 -
Medical Self-Management for Improving Health Behavior Among Individuals in Community Mental Health Settings
|
N/A |