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Completed

NCT Number: NCT03091036

Impact of a Health Intervention on Some Indicators in the Care of Chronic Complex Patient (CCP).

The aim of this study is to assess the effectiveness of proactive and integrated healthcare program for chronic complex patients (CCP). This program are based in coordination the primary level of attention with and speciality level. The objective is reducing hospital readmissions and know the benefit in total cost of care in 4 month before and 4 after intervention.

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Key information

Conditions

Preventive Care Bronchial Diseases Bronchiolitis Bronchiolitis Obliterans Bronchiolitis Obliterans Syndrome Bronchitis Graft vs Host Disease Immune System Diseases Lung Diseases Lung Diseases, Obstructive Organizing Pneumonia Respiratory Tract Diseases

Age range

75 year and older

Sex eligibility

All sexes

Study type

Interventional

Phase

Not applicable

Primary location

Hospital Universitario 12 de Octubre de Madrid

Madrid, 28041, Spain

About this study

Quasi-experimental study with single-arm (pre-post study design without control group). The investigators checking pre and post intervention the effectiveness of a healthcare program for CCP. The interventions consist:

  • - Help the nurse in the hospital to carry out the care plans and the continuity care report.
  • - Refer patients to the social workers.
  • - Collaborate with the social worker to refer to centers of media, long stay and reference hospital.
  • - Ensure the follow-up appointments for the CCP.
  • - Make proactive calls to the CCP and/or their caregiver after discharge
  • - Plan the hospital discharge 48 hours in advance, so that the family and the patient can be organized.

The investigator analysed if with this program, the CCP reducing hospital readmission and reducing the Hospital expenditure.

Who can participate

Healthy volunteers accepted: No

Only the study team can determine whether someone qualifies for participation.

Inclusion criteria

  • Patient ≥ 75 years.
  • Having attended 5 or more emergency visits or having had more than 3 hospital admissions in the last 12 months.
  • Identified with social risk alert.

Exclusion criteria

  • Participate in other health programs (AHT, diabetes mellitus,...).
  • Terminal patient.

Treatment and study plan

Proactive healthcare intervention

Other

There is an intervention in the coordination of health resources, and monitoring readmissions and know the benefit in total cost of care in 4 month.

Primary outcomes

  1. Pre-post change in days of Hospital stay from baseline to 16 weeks.

    Time frame: Baseline and 16 weeks.

    The same group of patients are analyzed the days of hospital stay at the end of 16 weeks of follow-up pre intervention (baseline) and 16 week after the intervention.

Secondary outcomes

  1. Number of hospital readmissions visits for CCP change from baseline to 16 weeks.

    Time frame: Baseline and 16 weeks.

    The same group of patients are analyzed the number of hospital readmissions visit for CCP at the end of 16 weeks pre intervention (considered baseline) of follow-up and 16 weeks after the intervention.

  2. Number of urgency visits for CCP change from baseline to 16 weeks.

    Time frame: Baseline and 16 weeks.

    The same group of patients are analyzed the number of urgency visits and primary care visit for CCP at the end of 16 weeks pre intervention (considered baseline) of follow-up and 16 weeks after the intervention.

  3. Number of primary care visits for CCP change from baseline to 16 weeks.

    Time frame: Baseline and 16 weeks.

    The same group of patients are analyzed the number of primary care visits for CCP at the end of 16 weeks pre intervention (considered baseline) of follow-up and 16 weeks after the intervention.

Sponsors and collaborators

Lead sponsor

María José del Olmo Rubio

Other

Collaborators

  • Hospital Universitario 12 de Octubre

Registry information

Official study title

Impact of a Proactive and Integrated Health Intervention Between Different Assistance Levels Over Some Indicators in the Care of Chronic Complex Patient (CCP)

Acronym: CCP

Important dates

Study start
2015
Primary completion
2016
Study completion
2017
First posted
Mar 27, 2017
Registry last updated
Apr 10, 2017

OpenTrials presents study information sourced from ClinicalTrials.gov. The official registry record should be consulted for the latest information.

View the official ClinicalTrials.gov record (opens in a new tab)

This listing is for discovery and informational purposes only. It is not medical advice, does not guarantee that a study is recruiting, and does not determine eligibility. Contact the study team and a qualified healthcare professional when considering participation.

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