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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1
Ashdod A
Ashdod, Israel
2
Ashdod D
Ashdod, Israel
3
Azur
Azor, Israel
4
Arlozorov
Bat Yam, Israel