An Integrated Care Model for Chronic Patients

Integrated Care Clinical Trial

Official title:

Effectiveness of the Integrated Care Model Salut+Social in Patients With Chronic Conditions: a Mixed Methods Study Protocol

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT04164160
• Other study ID #: 7Z18/020
• Status: Recruiting
• Phase: N/A
• Start date: June 1, 2019
• Est. completion date: June 30, 2020

Study information

• Verified date: October 2019
• Source: Jordi Gol i Gurina Foundation
• Contact: Pere M Zaragoza, BSc
• Phone: +34 934824253
• Email: pmonteagudo[@]idiapjgol.org
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Integrated care models aim to promote the coordination and communication between services. The present study aim to evaluate the effectiveness of a new integrated care model (Salut+Social model) which will promote the coordination and communication between social and healthcare services in southern Catalonia (Spain) for the improvement of quality of life of chronic patients, adherence to treatment, access to medical services and caregiver overload. Also, we will evaluate the experience of health and social professionals with the new model implemented.

Description:

A clinical trial with mixed methodology will be carried out. The intervention consists of the promotion and coordination between the social and health sectors, for 6 months, through the use of information and communication technology (ICT) tools that operate as an interface for the integrated care model. The study subjects are chronic patients with health and social conditions that are susceptible to be treated in a collaborative and coordinated way in the field of primary health care. A sample size of 141 patients was estimated. Questionnaires will be used at baseline and at 6, 9 and 12 months after the beginning of the study for the evaluation of quality of life, treatment adherence, medical service and caregiver overload. The principal variable is the quality of life. For statistical analysis, comparisons of means and proportions at different time points will be performed. One discussion group will be performed with the aim of improving the care model according to professionals' opinions. A thematic content analysis will be carried out.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 141
• Est. completion date: June 30, 2020
• Est. primary completion date: June 30, 2020
• Accepts healthy volunteers: No
• Gender: All
• Age group: N/A and older

Eligibility

Inclusion Criteria:

• Adult patients with at least one health and one social condition, as below specified:

1. health condition, according to diagnosis of the electronic medical history:

complex chronic patient; advanced chronic disease; patient in the home care program; dementia; neurodegenerative diseases; stroke; others chronic disease.

2. social condition, according to social service workstation from Ribera d'Ebre district: dependence grade; home social service assistance; teleassistance systems assigned by home support.

• Knowledgement of Spanish or Catalan.

• Accepting participation in the study (with informed consent signed by the patient or by the caregiver).

Exclusion Criteria:

• Institutionalized patients.

• Users with difficulties filling out or respond a questionnaire.

Related Conditions & MeSH terms

• Integrated Care

Intervention

Other:
• integrated-care-model benefiting group
Patients will be called for the ?rst interview of the study by the healthcare professional. Their data will be automatically entered in the Salut + Social app, they will be asked to respond to the study questionnaires (ad hoc questionnaire for sociodemographic data, EuroQol-5D, Zarit questionnaire and Morisky-Green test) and will take part in the future actions to be planned for them. Patients will receive an appointment to attend their PCC at 6, 9, and 12 months after their incorporation into the program. In those follow-up, the same questionnaires will be provided together with the IEXPAC questionnaire, which evaluates the experience of the chronic patient with the new care model.

Locations

Country	Name	City	State
Spain	Institut Català de la Salut	Tortosa	Tarragona

Sponsors (3)

Lead Sponsor	Collaborator
Jordi Gol i Gurina Foundation	Department of Health, Generalitat de Catalunya, Institut Català de la Salut

Country where clinical trial is conducted

Spain, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Change in life quality	to be evaluated with the EuroQol- 5 Dimension (EQ-5D). It will be measured by a scale Likert: 0 (worst) to 1 (best).	change from life quality at 6, 9 and 12 months after the beginning of the study.
Primary	Change in caregiver burden	to be evaluated with the Zarit Caregiver Burden Inventory. It will be measured by a scale Likert: 22 (best) to 110 (worst).	change from Zarit Caregiver Burden Inventory at 6, 9 and 12 months after the beginning of the study.
Primary	Change in adherence to treatment	be evaluated with the Morisky and Green test. It will be measured with a dichotomic variable: compliant (if response for the 4 questions is: No/Yes/No/No); noncompliant (if response for the 4 questions is different for: No/Yes/No/No).	change from Morisky and Green test at 6, 9 and 12 months after the beginning of the study.
Primary	Change in patient experience about his/her care	Be evaluated with the IEXPAC (Instrument for the Evaluation of the Chronic Patient's Experience). Each of the 11 items will be measured with 5-point Likert scale. The global punctuation is an average of the score of the each of the items: 0 (worst experience) to 10 (best experience).	change from IEXPAC at 6, 9 and 12 months after the beginning of the study
Secondary	Sociodemographic characteristics of the patients	age, sex, level of education, civil status, job situation, nationality	baseline (pre intervention period)
Secondary	Caregiver characteristics: caregiver with family relationship	To be evaluated with an ad hoc questionnaire (yes/no type)	baseline (pre intervention period)
Secondary	Caregiver characteristics: caregiver relationship	To be evaluated with an ad hoc questionnaire (1. Couple; 2. Mother; 3. Father; 4. Son; 5. Others).	baseline (pre intervention period)
Secondary	Caregiver characteristics: hours of support	To be evaluated with an ad hoc questionnaire (quantitative variable).	baseline (pre intervention period)