Status:

UNKNOWN

Comprehensive-Care for Multimorbid Adults Effectiveness Study

Lead Sponsor:

Meir Medical Center

Collaborating Sponsors:

Israel National Institute for Health Policy and Health Services Research

Conditions:

Chronic Disease

Eligibility:

All Genders

18-95 years

Phase:

NA

Brief Summary

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, pr...

Detailed Description

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 differe...

Eligibility Criteria

Inclusion

  • ACG system high risk probabilty score - 4% Highest Risk Score
  • Age 18 and older
  • 2 or more chronic conditions

Exclusion

  • Patients already included in a controlled disease management program (e.g., COPD disease management and telehealth).
  • Participation in any medical research.
  • Confined to bed.
  • Inpatient nursing care, nursing homes.
  • Kidney, liver or heart transplant patients.
  • Active (receipt of oncology chemotherapy , radiotherapy or other oncology treatment during the past 3 years).
  • Dialysis patients.
  • Clalit Healthcare Services employees.
  • Patients with major active mental illness, such as schizophrenia.
  • Cognitive failure.
  • Non Hebrew speaking patients without Hebrew speaking primary informal caregiver.
  • Bedridden patients
  • Housebound patients

Key Trial Info

Start Date :

March 1 2013

Trial Type :

INTERVENTIONAL

Allocation :

ESTIMATED

End Date :

March 1 2017

Estimated Enrollment :

1800 Patients enrolled

Trial Details

Trial ID

NCT01811173

Start Date

March 1 2013

End Date

March 1 2017

Last Update

April 29 2015

Active Locations (13)

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Page 1 of 4 (13 locations)

1

Ashdod A

Ashdod, Israel

2

Ashdod D

Ashdod, Israel

3

Azur

Azor, Israel

4

Arlozorov

Bat Yam, Israel