Chronic Care Management for Adults at FQHCs

NCT02136732 | Unknown DMC

• 1 other identifier: 1R01AG042467-01A1
• Study Type: interventional
• Target: 290
• Locations: 1 country
• Sites: 1

Brief Summary

With a growing aging population, the number of persons with chronic conditions continues to escalate and challenges related to chronic care quality, effectiveness and cost remain unresolved.Federally Qualified Health Centers (FQHC) have experienced increasing numbers of patient visits for chronic conditions, and FQHC patients are more likely to have serious chronic conditions when compared to patients being cared for by non-FQHC providers. The Chronic Care Intervention (CCI) combines home visiting with health activation coaching and has resulted in improved health status and reduced expenditures (Preliminary Studies). Implementing the CCI for aging adults with multimorbidity (2 or more chronic conditions) and high baseline acute care utilization, allows us to test and expand the efficacy, external validity and cost effectiveness of the proposed intervention model. The investigators seek to improve patients' and FQHCs' abilities to effectively manage chronic conditions and reduce acute care use. This contribution is significant because it potentially extends our knowledge about effective community partnerships and best practices that can enhance the effectiveness of health homes in providing patient-centered team-based care for patients with multimorbidity and high baseline health care utilization.

Conditions

Any Condition in N73.0 Specified as Chronic

Keywords

chronic conditions; multimorbid

Outcome Measures

Primary Outcomes (1)

• patient activation

  Patient activation will be measured using the Patient Activation Measure. Higher scores on this tool indicate that the patient is more involved in self-managing care and partnering with health care professionals to achieve better health outcomes.

  change from baseline to 3, 6, and 12 months

Secondary Outcomes (1)

• acute care utilization

  change in acute care utilization from baseline year to intervention year

Other Outcomes (1)

• Participant's Health-Related Quality of Life.

  change in quality of life from baseline to 3 months, 6 months, 9 months, 12 months.

Study Arms (2)

Active self-management intervention

EXPERIMENTAL

Participants will receive home visits and phone calls from a registered nurse and social worker. The registered nurse and social worker will provide participants one on one coaching, education, support and referrals to community resources to help them manage their chronic conditions.

Other: Active self-management intervention

Attention control phone calls

ACTIVE COMPARATOR

Participants will receive an initial visit and then a phone call every other month from a social services aide who can provide information about community resources that might be helpful.

Other: Attention control phone calls

Interventions

Active self-management intervention OTHER

Participants will set health goals at baseline. They will then receive, at minimum, a visit or a phone call to assess how progress and coaching toward meeting goals on a monthly basis from a nurse and/or social worker. The frequency and exact activities associated with the intervention are dependent on each participant's unique health goals.

Active self-management intervention

Attention control phone calls OTHER

Participants will be called by a social service aide at 2, 4, 6, 8, 10, and 12 months.

Attention control phone calls

Eligibility Criteria

• Age: 45 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• years of age or older, 2 or more chronic conditions, 2 or more emergency department visits or hospital admissions in previous 12 months.

You may not qualify if:

• terminal illness, dementia, case management elsewhere, resident of adult family home, boarding home or skilled nursing facility, homeless.

Sponsors & Collaborators

• Washington State University: lead
• Community Health Association of Spokane: collaborator
• Aging and Long Term Care of Eastern Washington: collaborator

Study Sites (1)

Community Health Association of Spokane

Spokane, Washington, 99201, United States

Location

MeSH Terms

Conditions

Chronic Disease

Condition Hierarchy (Ancestors)

Disease Attributes; Pathologic Processes; Pathological Conditions, Signs and Symptoms

Study Officials

• Cynthia Corbett, Ph.D.

  Washington State University College of Nursing

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: SINGLE
• Who Masked: OUTCOMES ASSESSOR
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: November 7, 2013
• First Posted: May 13, 2014
• Study Start: October 1, 2013
• Primary Completion: June 1, 2017
• Study Completion: June 1, 2017
• Last Updated: May 18, 2017

Record last verified: 2017-05

Locations

US (1)