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
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