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

Impact of a Proactive and Integrated Health Intervention Between Different Assistance Levels Over 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.

Study Overview

• Status: Completed
• Conditions: Preventive Care
• Intervention / Treatment: Other: Proactive healthcare intervention

Detailed Description

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:

1. - Help the nurse in the hospital to carry out the care plans and the continuity care report.
2. - Refer patients to the social workers.
3. - Collaborate with the social worker to refer to centers of media, long stay and reference hospital.
4. - Ensure the follow-up appointments for the CCP.
5. - Make proactive calls to the CCP and/or their caregiver after discharge
6. - 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.

• Study Type: Interventional
• Enrollment (Actual): 28
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Spain
  • Madrid, Spain, 28041
    • Hospital Universitario 12 de Octubre de Madrid

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 75 years and older (Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

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.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Other: Proactive healthcare intervention; Participants who were included before (single-arm pre-post study), now a proactive and integrated intervention program for the health is performed of the complex chronic patient, based in an improvement of the care process.	Other: Proactive healthcare intervention; 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.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Pre-post change in days of Hospital stay from baseline to 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.	Baseline and 16 weeks.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of hospital readmissions visits for CCP change from baseline to 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.	Baseline and 16 weeks.
Number of urgency visits for CCP change from baseline to 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.	Baseline and 16 weeks.
Number of primary care visits for CCP change from baseline to 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.	Baseline and 16 weeks.

Collaborators and Investigators

• Sponsor: María José del Olmo Rubio
• Collaborators: Hospital Universitario 12 de Octubre
• Investigators: Principal Investigator: María José del Olmo Rubio, Hospital 12 de Octubre de Madrid

Study record dates

Study Major Dates

• Study Start: July 1, 2015
• Primary Completion (Actual): July 1, 2016
• Study Completion (Actual): January 1, 2017

Study Registration Dates

• First Submitted: March 16, 2017
• First Submitted That Met QC Criteria: March 21, 2017
• First Posted (Actual): March 27, 2017

Study Record Updates

• Last Update Posted (Actual): April 10, 2017
• Last Update Submitted That Met QC Criteria: April 7, 2017
• Last Verified: April 1, 2017

More Information

Terms related to this study

• Keywords: Chronic; Complex
• Other Study ID Numbers: InveCuidPCC16

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No