Chronic Care Management for Adults at FQHCs

NCT ID: NCT02136732

Last Updated: 2017-05-18

Basic Information

• Recruitment Status: UNKNOWN
• Clinical Phase: NA
• Total Enrollment: 290 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2013-10-31
• Study Completion Date: 2017-06-30

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.

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.

Conditions

Any Condition in N73.0 Specified as Chronic

Study Design

• Allocation Method: RANDOMIZED
• Intervention Model: PARALLEL
• Primary Study Purpose: HEALTH_SERVICES_RESEARCH
• Blinding Strategy: SINGLE

Study Groups

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.

Group Type: EXPERIMENTAL

Active self-management intervention

Intervention Type: 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.

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.

Group Type: ACTIVE_COMPARATOR

Attention control phone calls

Intervention Type: OTHER

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

Interventions

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.

Intervention Type: OTHER

Attention control phone calls

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

Intervention Type: OTHER

Eligibility 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.

• Minimum Eligible Age: 45 Years
• Eligible Sex: ALL
• Accepts Healthy Volunteers: No

Sponsors

Community Health Association of Spokane

UNKNOWN

Sponsor Role: collaborator

Aging and Long Term Care of Eastern Washington

UNKNOWN

Sponsor Role: collaborator

Washington State University

OTHER

Sponsor Role: lead

Responsible Party

Responsibility Role: SPONSOR

Principal Investigators

Cynthia Corbett, Ph.D.

Role: PRINCIPAL_INVESTIGATOR

Washington State University College of Nursing

Locations

Community Health Association of Spokane

Spokane, Washington, United States

Countries

United States

Other Identifiers

1R01AG042467-01A1

Identifier Type: NIH

Identifier Source: org_study_id

View Link