Impact of a Health Intervention on Some Indicators in the Care of Chronic Complex Patient (CCP).

Preventive Care Clinical Trial

— CCP  

Official title:

Impact of a Proactive and Integrated Health Intervention Between Different Assistance Levels Over Some Indicators in the Care of Chronic Complex Patient (CCP)

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT03091036
• Other study ID #: InveCuidPCC16
• Status: Completed
• Phase: N/A
• First received: March 16, 2017
• Last updated: April 7, 2017
• Start date: July 2015
• Est. completion date: January 2017

Study information

• Verified date: April 2017
• Source: Hospital Universitario 12 de Octubre
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The aim of this study is to assess the effectiveness of proactive and integrated healthcare program for chronic complex patients (CCP). This program are based in coordination the primary level of attention with and speciality level. The objective is reducing hospital readmissions and know the benefit in total cost of care in 4 month before and 4 after intervention.

Description:

Quasi-experimental study with single-arm (pre-post study design without control group). The investigators checking pre and post intervention the effectiveness of a healthcare program for CCP. The interventions consist:

1. - Help the nurse in the hospital to carry out the care plans and the continuity care report.

2. - Refer patients to the social workers.

3. - Collaborate with the social worker to refer to centers of media, long stay and reference hospital.

4. - Ensure the follow-up appointments for the CCP.

5. - Make proactive calls to the CCP and/or their caregiver after discharge

6. - Plan the hospital discharge 48 hours in advance, so that the family and the patient can be organized.

The investigator analysed if with this program, the CCP reducing hospital readmission and reducing the Hospital expenditure.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 28
• Est. completion date: January 2017
• Est. primary completion date: July 2016
• Accepts healthy volunteers: No
• Gender: All
• Age group: 75 Years and older

Eligibility

Inclusion Criteria:

• Patient = 75 years.

• Having attended 5 or more emergency visits or having had more than 3 hospital admissions in the last 12 months.

• Identified with social risk alert.

Exclusion Criteria:

• Participate in other health programs (AHT, diabetes mellitus,...).

• Terminal patient.

Related Conditions & MeSH terms

• Preventive Care

Intervention

Other:
• Proactive healthcare intervention
There is an intervention in the coordination of health resources, and monitoring readmissions and know the benefit in total cost of care in 4 month.

Locations

Country	Name	City	State
Spain	Hospital Universitario 12 de Octubre de Madrid	Madrid

Sponsors (2)

Lead Sponsor	Collaborator
María José del Olmo Rubio	Hospital Universitario 12 de Octubre

Country where clinical trial is conducted

Spain, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Pre-post change in days of Hospital stay from baseline to 16 weeks.	The same group of patients are analyzed the days of hospital stay at the end of 16 weeks of follow-up pre intervention (baseline) and 16 week after the intervention.	Baseline and 16 weeks.
Secondary	Number of hospital readmissions visits for CCP change from baseline to 16 weeks.	The same group of patients are analyzed the number of hospital readmissions visit for CCP at the end of 16 weeks pre intervention (considered baseline) of follow-up and 16 weeks after the intervention.	Baseline and 16 weeks.
Secondary	Number of urgency visits for CCP change from baseline to 16 weeks.	The same group of patients are analyzed the number of urgency visits and primary care visit for CCP at the end of 16 weeks pre intervention (considered baseline) of follow-up and 16 weeks after the intervention.	Baseline and 16 weeks.
Secondary	Number of primary care visits for CCP change from baseline to 16 weeks.	The same group of patients are analyzed the number of primary care visits for CCP at the end of 16 weeks pre intervention (considered baseline) of follow-up and 16 weeks after the intervention.	Baseline and 16 weeks.