Comprehensive-Care for Multimorbid Adults Effectiveness Study
CCMAP
The Clalit Comprehensive-Care for Multimorbid Adults Project
1 other identifier
interventional
1,800
1 country
13
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, proactive follow-up, self management support and caregiver support and care coordination, can reduce hospital admissions for patients with multiple chronic conditions.
Trial Health
Trial Health Score
Automated assessment based on enrollment pace, timeline, and geographic reach
participants targeted
Target at P75+ for not_applicable
Started Mar 2013
Longer than P75 for not_applicable
13 active sites
Health score is calculated from publicly available data and should be used for screening purposes only.
Trial Relationships
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Study Timeline
Key milestones and dates
Study Start
First participant enrolled
March 1, 2013
CompletedFirst Submitted
Initial submission to the registry
March 12, 2013
CompletedFirst Posted
Study publicly available on registry
March 14, 2013
CompletedPrimary Completion
Last participant's last visit for primary outcome
March 1, 2017
CompletedStudy Completion
Last participant's last visit for all outcomes
March 1, 2017
CompletedApril 29, 2015
February 1, 2013
4 years
March 12, 2013
April 28, 2015
Conditions
Keywords
Outcome Measures
Primary Outcomes (1)
Percent change in admissions for ambulatory care sensetive conditions
Ambulatory Care Sensitive Conditions will be defined by ICD-9 codes, based on the classification published by: Ansari, Barbetti, Carson, Auckland, \& Cicuttini, 2003 (adapted from Weissman JS, Gatsonis C, Epstein AM ,1992; Millman M, ed. 1993)
At enrollment and within 12 months and 24 months after enrollment
Secondary Outcomes (1)
Emergency 30-day readmissions
30 days post an index admission
Other Outcomes (1)
Change in SF-12 Physical and Menal component scores
At enrollment and 6, 12, and 24 months after enrollment
Study Arms (3)
Nurse-physician comprehensive care
EXPERIMENTALComprehensive self management support and care coordination by a nurse-primary care physician team
Usual care survey control group
NO INTERVENTIONPatients will receive usual primary care and asked to complete questionnaires on four time points throughout the study
Usual care blinded control group
NO INTERVENTIONPatients will receive usual primary care.
Interventions
Components of the intervention include: 1. Complete assessment of the patient's and family's needs conducted by the nurse. 2. Comprehensive treatment program developed by the nurse and in consultation with the primary care physician. 3. "Multimorbid care plan" integrating all care aspects. 4. "Action Plan" for patients, supporting self management 5. Proactive monitoring according to the plan.
Eligibility Criteria
You may qualify if:
- ACG system high risk probabilty score - 4% Highest Risk Score
- Age 18 and older
- or more chronic conditions
You may not qualify if:
- 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
Contact the study team to confirm eligibility.
Sponsors & Collaborators
Study Sites (13)
Ashdod A
Ashdod, Israel
Ashdod D
Ashdod, Israel
Azur
Azor, Israel
Arlozorov
Bat Yam, Israel
Hashikma
Bat Yam, Israel
Ramat Yosef
Bat Yam, Israel
Sokolov
Bat Yam, Israel
Halutz
Hulon, Israel
Shikun Ammi
Hulon, Israel
Lod Center
Lod, Israel
Ramla Ztafon
Ramla, Israel
Balfur
Rishon LeZiyyon, Israel
Migdal HaIr
Rishon LeZiyyon, Israel
Related Publications (2)
Cohen-Stavi CJ, Giveon S, Key C, Molcho T, Balicer R, Shadmi E. Guideline deviation and its association with specific chronic diseases among patients with multimorbidity: a cross-sectional cohort study in a care management setting. BMJ Open. 2021 Jan 11;11(1):e040961. doi: 10.1136/bmjopen-2020-040961.
PMID: 33431488DERIVEDSteinman MA, Low M, Balicer RD, Shadmi E. Impact of a nurse-based intervention on medication outcomes in vulnerable older adults. BMC Geriatr. 2018 Sep 6;18(1):207. doi: 10.1186/s12877-018-0905-1.
PMID: 30189846DERIVED
MeSH Terms
Conditions
Condition Hierarchy (Ancestors)
Study Officials
- PRINCIPAL INVESTIGATOR
Ran D Balicer, PhD
Clalit Research Institute, Clalit Health Services
Study Design
- Study Type
- interventional
- Phase
- not applicable
- Allocation
- NON RANDOMIZED
- Masking
- NONE
- Purpose
- HEALTH SERVICES RESEARCH
- Intervention Model
- PARALLEL
- Sponsor Type
- OTHER
- Responsible Party
- SPONSOR
Study Record Dates
First Submitted
March 12, 2013
First Posted
March 14, 2013
Study Start
March 1, 2013
Primary Completion
March 1, 2017
Study Completion
March 1, 2017
Last Updated
April 29, 2015
Record last verified: 2013-02