Model for the Integral Assessment of Chronic Disease Management Supported in Information Technology and Communication.

Instituto de Investigacion Sanitaria La Fe

Status

Completed

Conditions

Chronic Disease

Treatments

Other: Phone-based care group

Other: Usual care group

Device: Platform NOMHADchronic

Study type

Interventional

Funder types

Other

Identifiers

NCT02447562

GECHRONIC

Details and patient eligibility

About

Controlled and Randomized Clinical trial with 3 parallel groups (intervention group with a health platform NOMHADchronic, phone-based care group, usual care group) developed in the Valencia La Fe Health Department. 495 high-complexity chronic patients will be included according to a combined recruitment based on a risk predictive model plus clinical opinion. Patients will be followed-up during 12 months in order to evaluate health-related quality of life, mortality, health consumption, health direct cost and treatment satisfaction.

Enrollment

495 patients

Sex

Ages

18+ years old

Volunteers

No Healthy Volunteers

Inclusion criteria

Age ≥18 years old.
High complexity: according to a combined criteria a) predictive model of Valencia La Fe Health department for hospital resources consumption in next 12 months (probability >95%) and b) risk confirmation by a clinical team with experience on chronic patients management.
Participants that accept to participate in the study by the informed consent signature
Participants that don't meet any of the exclusion criteria

Exclusion criteria

Age <18 años.
Participants with cognitive or sensorial difficulties or with insufficient knowledge of one of the 2 official languages of Valencian Community that, according to the healthcare professional, may affect their study participation.
No residents or temporary residents in the Health Department
Homeless or participants with high-risk of social exclusion.
Terminal patients or in palliative care according to the SECPAL (Spanish Society of Palliative Care) criteria .
Community-dwelling patients
Inability for mobile phone management if there is a caregiver with this capability.
Participants without a phone line
Non high-complexity chronic patients according to the recruitment healthcare professional.
Members of the research team, workers related to the centers implied in the study or any other person directly involved in the study -
First degree consanguinity or similar affinity with the team members.
Participants already involved in case management.
Participants already participating in clinical trials or experimental trials.
Participants that don't accept to participate in the study or not signing the informed consent
Participants with a main diagnostic of mental diseases
Participants with active oncological diagnosis
Participants already following specific interventions for hemodialysis, organ transplanting, day hospital
Participants with an infectious chronic disease as unique chronic disease (HIV, BHV (Hepatitis B Virus)...)