An Integrated Care Model for Chronic Patients

NCT04164160 | Unknown

• 1 other identifier: 7Z18/020
• Study Type: interventional
• Target: 141
• Locations: 1 country
• Sites: 1

Brief Summary

Integrated care models aim to promote the coordination and communication between services. The present study aim to evaluate the effectiveness of a new integrated care model (Salut+Social model) which will promote the coordination and communication between social and healthcare services in southern Catalonia (Spain) for the improvement of quality of life of chronic patients, adherence to treatment, access to medical services and caregiver overload. Also, we will evaluate the experience of health and social professionals with the new model implemented.

Conditions

Integrated Care

Keywords

Integrated care; Health and social care; Chronic disease; Primary Health Care; Quality of life

Outcome Measures

Primary Outcomes (4)

• Change in life quality

  to be evaluated with the EuroQol- 5 Dimension (EQ-5D). It will be measured by a scale Likert: 0 (worst) to 1 (best).

  change from life quality at 6, 9 and 12 months after the beginning of the study.

• Change in caregiver burden

  to be evaluated with the Zarit Caregiver Burden Inventory. It will be measured by a scale Likert: 22 (best) to 110 (worst).

  change from Zarit Caregiver Burden Inventory at 6, 9 and 12 months after the beginning of the study.

• Change in adherence to treatment

  be evaluated with the Morisky and Green test. It will be measured with a dichotomic variable: compliant (if response for the 4 questions is: No/Yes/No/No); noncompliant (if response for the 4 questions is different for: No/Yes/No/No).

  change from Morisky and Green test at 6, 9 and 12 months after the beginning of the study.

• Change in patient experience about his/her care

  Be evaluated with the IEXPAC (Instrument for the Evaluation of the Chronic Patient's Experience). Each of the 11 items will be measured with 5-point Likert scale. The global punctuation is an average of the score of the each of the items: 0 (worst experience) to 10 (best experience).

  change from IEXPAC at 6, 9 and 12 months after the beginning of the study

Secondary Outcomes (4)

• Sociodemographic characteristics of the patients

  baseline (pre intervention period)

• Caregiver characteristics: caregiver with family relationship

  baseline (pre intervention period)

• Caregiver characteristics: caregiver relationship

  baseline (pre intervention period)

• Caregiver characteristics: hours of support

  baseline (pre intervention period)

Study Arms (1)

integrated-care-model benefiting group

EXPERIMENTAL

Chronic patients whose clinical and social data will be added in the integrated care model application software.

Other: integrated-care-model benefiting group

Interventions

integrated-care-model benefiting group OTHER

Patients will be called for the first interview of the study by the healthcare professional. Their data will be automatically entered in the Salut + Social app, they will be asked to respond to the study questionnaires (ad hoc questionnaire for sociodemographic data, EuroQol-5D, Zarit questionnaire and Morisky-Green test) and will take part in the future actions to be planned for them. Patients will receive an appointment to attend their PCC at 6, 9, and 12 months after their incorporation into the program. In those follow-up, the same questionnaires will be provided together with the IEXPAC questionnaire, which evaluates the experience of the chronic patient with the new care model.

integrated-care-model benefiting group

Eligibility Criteria

• Sex: all
• Healthy Volunteers: No
• Age Groups: Child (0-17), Adult (18-64), Older Adult (65+)

You may qualify if:

• Adult patients with at least one health and one social condition, as below specified:
• health condition, according to diagnosis of the electronic medical history: complex chronic patient; advanced chronic disease; patient in the home care program; dementia; neurodegenerative diseases; stroke; others chronic disease.
• social condition, according to social service workstation from Ribera d'Ebre district: dependence grade; home social service assistance; teleassistance systems assigned by home support.
• Knowledgement of Spanish or Catalan.
• Accepting participation in the study (with informed consent signed by the patient or by the caregiver).

You may not qualify if:

• Institutionalized patients.
• Users with difficulties filling out or respond a questionnaire.

Sponsors & Collaborators

• Fundacio d'Investigacio en Atencio Primaria Jordi Gol i Gurina: lead
• Institut Català de la Salut: collaborator
• Department of Health, Generalitat de Catalunya: collaborator

Study Sites (1)

Institut Català de la Salut

Tortosa, Tarragona, 43500, Spain

RECRUITING

Related Publications (1)

• Gavalda-Espelta E, Del Mar Lleixa-Fortuno M, Baucells-Lluis J, Ferre-Ferrate M, Mora-Lopez G, Tomas-Navarro B, Curto-Romeu C, Lucas-Noll J, Aguilar Martin C, Goncalves AQ, Ferre-Grau C. Effectiveness of the integrated care model Salut+Social in patients with chronic conditions: A mixed methods study protocol. Medicine (Baltimore). 2020 May;99(19):e19994. doi: 10.1097/MD.0000000000019994.

  PMID: 32384454 DERIVED

MeSH Terms

Conditions

Chronic Disease

Condition Hierarchy (Ancestors)

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

Central Study Contacts

Pere M Zaragoza, BSc

CONTACT

+34 934824253; pmonteagudo@idiapjgol.org

Alessandra Q Gonçalves, PhD

CONTACT

+34 977504949; aqueiroga@idiapjgol.info

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: NA
• Masking: NONE
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: SINGLE GROUP
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: November 13, 2019
• First Posted: November 15, 2019
• Study Start: June 1, 2019
• Primary Completion: June 30, 2020
• Study Completion: June 30, 2020
• Last Updated: March 23, 2020

Record last verified: 2019-10

Locations

ES (1)