Status:
TERMINATED
Primary Care Based Integrated Community Care Team Intervention
Lead Sponsor:
SingHealth Polyclinics
Collaborating Sponsors:
Ministry of Health, Singapore
Agency for Integrated Care, Singapore
Conditions:
Diabetes
Diabetes Mellitus
Eligibility:
All Genders
50+ years
Phase:
NA
Brief Summary
PACE-It study is a non-blinded, mix-method randomized controlled trial within a single site. This study aims to test the feasibility of implementing a complex intervention comprising of a) a Primary C...
Detailed Description
PACE-It study aims to test the feasibility of implementing a complex intervention comprising of a) a Primary Care Based Community Care Team delivery of person centered care b) supported by a care co-o...
Eligibility Criteria
Inclusion
- Living within the designated geographical zone
- 50 years and above
- Satisfy the Medical Criteria below:
- Diabetes with HbA1c ≥ 9% (within past 6 months), and
- At least 1 complication
- chronic kidney impairment stage 3 and above, or diabetes overt nephropathy,
- ischaemic heart disease, or congestive cardiac failure,
- peripheral arterial disease, or diabetes foot/ diabetes foot-related complications,
- diabetic retinopathy/ treatment for retinopathy, and
- stroke, or transient ischaemic attack
- Satisfy at least 2 conditions in the psycho-social, functional or activation domain of which 1 criteria must be from the psycho-social domain:
- Psycho-social issues
- a. Lack of care giver support i. No care-giver (when indicated) ii. Care-giver skills gap/ stress iii. Inability of copy when patient is the care-giver b. Difficult relationships (family/ workplace/ social network) c. Social isolation/ lack of social connectivity i. Lives alone ii. Lack of social network support d. Financial i. Financial difficulty/ insecurity ii. Housing/ shelter issues iii. Poor money management
- Functional
- Clinical Frailty Score ≥ 4, requiring help in instrumental activities of daily living (iADL)
- Requires assistance in ADL or iADL
- Activation a. Lack of ability to manage health - disengaged or overwhelmed i. Anxiety or disease-related distress ii. Confusion or lack of understanding of care plans iii. Non-adherence to medications/ follow up
- Patient gives consent to participate
- For patients who may be seeing a Primary Care Physician (PCP) outside of the polyclinic for chronic disease management and where the PCP has indicated consent to co-manage the patient with the PACE-It team including the polyclinic physician
- Patient must be willing to receive care in the polyclinic
Exclusion
- Patients who are on follow up with Primary Care Physicians or General Practitioners elsewhere for management of their chronic conditions and they do not consent to co-managing patient with the PACE-It team
- Patients who have severe cognitive impairment, depression or psychiatric conditions that interfere with the ability to engage with the healthcare team
- Patients who are (i) not community ambulant or (ii) bed bound
- Patients with terminal illness
- Patients who have are in other programs or research studies
- Patients who do not give consent
Key Trial Info
Start Date :
December 7 2020
Trial Type :
INTERVENTIONAL
Allocation :
ACTUAL
End Date :
February 8 2022
Estimated Enrollment :
41 Patients enrolled
Trial Details
Trial ID
NCT04819256
Start Date
December 7 2020
End Date
February 8 2022
Last Update
April 28 2022
Active Locations (1)
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1
SingHealth Polyclinics - Marine Parade, 80 Marine Parade Central, #01-792
Singapore, Singapore, 440080