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Chronic Care Management for Adults at FQHCs

This study is ongoing, but not recruiting participants.
Sponsor:
Collaborators:
Community Health Association of Spokane
Aging and Long Term Care of Eastern Washington
Information provided by (Responsible Party):
Washington State University
ClinicalTrials.gov Identifier:
NCT02136732
First received: November 7, 2013
Last updated: May 16, 2017
Last verified: May 2017
  Purpose

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.


Condition Intervention
Any Condition in N73.0 Specified as Chronic Other: Active self-management intervention Other: Attention control phone calls

Study Type: Interventional
Study Design: Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary Purpose: Health Services Research
Official Title: Chronic Care Management Model Translation to Multimorbid Aging Adults at FQHCs

Further study details as provided by Washington State University:

Primary Outcome Measures:
  • patient activation [ Time Frame: change from baseline to 3, 6, and 12 months ]
    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.


Secondary Outcome Measures:
  • acute care utilization [ Time Frame: change in acute care utilization from baseline year to intervention year ]
    Acute care utilization is defined as visits to the emergency department and admissions to the hospital


Other Outcome Measures:
  • Participant's Health-Related Quality of Life. [ Time Frame: change in quality of life from baseline to 3 months, 6 months, 9 months, 12 months. ]

Enrollment: 290
Study Start Date: October 2013
Estimated Study Completion Date: June 2017
Estimated Primary Completion Date: June 2017 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Experimental: Active self-management intervention
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
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 Comparator: Attention control phone calls
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
Participants will be called by a social service aide at 2, 4, 6, 8, 10, and 12 months.

Detailed Description:

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. Effectively managing multiple chronic conditions is particularly challenging for both patients and health professionals, and costs of care rise as the number of co-morbid conditions increases. FQHCs primarily serve patients with public insurance or those who are uninsured. Consequently, simultaneously controlling costs and improving chronic care is a critical issue for the FQHC system. Two approaches that have been used to improve health status and reduce health care utilization are preventive home visiting and patient activation counseling. Preventive home visiting allows for multidimensional assessment and individualized, patient-centered care, and there is wide agreement that engaging patients to be an active part of the care process is an essential element of the quality of care. This concept is known as "health activation".

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.

  Eligibility

Ages Eligible for Study:   45 Years and older   (Adult, Senior)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

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

Exclusion Criteria:

  • terminal illness, dementia, case management elsewhere, resident of adult family home, boarding home or skilled nursing facility, homeless.
  Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT02136732

Locations
United States, Washington
Community Health Association of Spokane
Spokane, Washington, United States, 99201
Sponsors and Collaborators
Washington State University
Community Health Association of Spokane
Aging and Long Term Care of Eastern Washington
Investigators
Principal Investigator: Cynthia Corbett, Ph.D. Washington State University College of Nursing
  More Information

Responsible Party: Washington State University
ClinicalTrials.gov Identifier: NCT02136732     History of Changes
Other Study ID Numbers: 1R01AG042467-01A1 ( U.S. NIH Grant/Contract )
Study First Received: November 7, 2013
Last Updated: May 16, 2017

Keywords provided by Washington State University:
chronic conditions
multimorbid

ClinicalTrials.gov processed this record on September 25, 2017