Primary Care Based Integrated Community Care Team Intervention (PACE-It)

SingHealth Polyclinics

Status

Terminated

Conditions

Diabetes

Diabetes Mellitus

Diabetes Mellitus, Type 2

Diabetes type2

Treatments

Other: PACE-It mobile application

Study type

Interventional

Funder types

Other

Identifiers

NCT04819256

2020/2202

Details and patient eligibility

About

PACE-It study is a non-blinded, mix-method randomized controlled trial within a single site. This study aims to test the feasibility of implementing a complex intervention comprising of a) a Primary Care Based integrated community care team delivery of person centered care, b) supported by a care co-ordination platform using a mobile application and its effectiveness in improving the glycemic control of patients living with Diabetes and have complex needs.

Full description

PACE-It study aims to test the feasibility of implementing a complex intervention comprising of a) a Primary Care Based Community Care Team delivery of person centered care b) supported by a care co-ordination platform using a mobile application and its effectiveness in improving the glycemic control of patients living with Diabetes and complex needs.

This is a non-blinded, mix-method randomised controlled trial within the Marine Parade Community. The primary outcome will be glycemic control measure by the Glycated Haemoglobin (HbA1c). Secondary outcomes include blood pressure, LDL-cholesterol, Patient Activation Measure, Medication Adherence and Quality of Life. Data on patient and provider satisfaction and implementation process will be collected by the Qualitative method.

Enrollment

41 patients

Sex

All

Ages

50+ years old

Volunteers

No Healthy Volunteers

Inclusion criteria

Living within the designated geographical zone
50 years and above
Satisfy the Medical Criteria below:
1. Diabetes with HbA1c ≥ 9% (within past 6 months), and
2. At least 1 complication
  1. chronic kidney impairment stage 3 and above, or diabetes overt nephropathy,
  2. ischaemic heart disease, or congestive cardiac failure,
  3. peripheral arterial disease, or diabetes foot/ diabetes foot-related complications,
  4. diabetic retinopathy/ treatment for retinopathy, and
  5. stroke, or transient ischaemic attack
Satisfy at least 2 conditions in the psycho-social, functional or activation domain of which 1 criteria must be from the psycho-social domain:
1. Psycho-social issues
  
  a. Lack of care giver support i. No care-giver (when indicated) ii. Care-giver skills gap/ stress iii. Inability of copy when patient is the care-giver b. Difficult relationships (family/ workplace/ social network) c. Social isolation/ lack of social connectivity i. Lives alone ii. Lack of social network support d. Financial i. Financial difficulty/ insecurity ii. Housing/ shelter issues iii. Poor money management
2. Functional
  1. Clinical Frailty Score ≥ 4, requiring help in instrumental activities of daily living (iADL)
  2. Requires assistance in ADL or iADL
3. Activation a. Lack of ability to manage health - disengaged or overwhelmed i. Anxiety or disease-related distress ii. Confusion or lack of understanding of care plans iii. Non-adherence to medications/ follow up
Patient gives consent to participate
For patients who may be seeing a Primary Care Physician (PCP) outside of the polyclinic for chronic disease management and where the PCP has indicated consent to co-manage the patient with the PACE-It team including the polyclinic physician
Patient must be willing to receive care in the polyclinic

Exclusion criteria

Patients who are on follow up with Primary Care Physicians or General Practitioners elsewhere for management of their chronic conditions and they do not consent to co-managing patient with the PACE-It team
Patients who have severe cognitive impairment, depression or psychiatric conditions that interfere with the ability to engage with the healthcare team
Patients who are (i) not community ambulant or (ii) bed bound
Patients with terminal illness
Patients who have are in other programs or research studies
Patients who do not give consent