Trial Details

Not Recruiting
Basic Information
Clinical ID c2715
Identifier RPCEC00000293
Trial Title Effectiveness of a case management model for the comprehensive provision of health services to multi-pathological patients - CMCOL-2018
Trial URL Visit Original Page
Study Information
Study Results

No results available
Conditions Multi-pathological condition. According with Working Group of the Sociedad Espala de Medicina Interna (SEMI), a patients are defined as multi-pathological or polypathological when they have chronic diseases that belong to two or more of the eight next categories: - Category A: NYHA heart failure class II (slight limitation of physical activity, in which ordinary physical activity causes dyspnea, angina, fatigue or palpitations). Ischemic heart disease.__- Category B: Vasculitis and systemic autoimmune diseases. Chronic kidney disease defined by elevated creatinine (>1.4 mg/dL in men or >1.3 mg/dL in women) or proteinuria (albumin/creatinine ratio >300 mg/g, microalbuminuria >3mg/dL in urine sample or albumin >300 mg/day in 24-hour urine, for 3 months).__- Category C: Chronic respiratory disease classified as MCR grade 2 (unable to keep the pace of another person of the same age; short breath when walking on level ground at own pace due to respiratory distress which requires rest; dyspnea assessed with the Medical Research Council (MRC) scale or FEV1 1.7, Albumin 2 mg/dL) or portal hypertension (defined by the presence of clinical, analytical, sonographic or endoscopic data).__- Category E: Stroke. Neurological disease with permanent motor deficit that causes a limitation in the basic activities of daily living (Barthel index less than 60). Neurological disease with permanent, at least moderate, cognitive impairment (Pfeiffer with 5 or more errors)__- Category F: Symptomatic peripheral arteriopathy. Diabetes mellitus with proliferative retinopathy or symptomatic neuropathy.__- Category G: Chronic anemia due to digestive losses or acquired hemopathy secondary to curative treatment with Hb <10mg/dL in two separate determinations for more than three months. Active solid or hematologic neoplasm not secondary to treatment w;Multiple Chronic Conditions;Chronic Disease
Interventions The recruitment process will follow 2 ways: 1.Based on the characterization, the target population recorded in the database of the insurance health company will be invited to participate until the estimated sample size is completed. 2. During the hospitalization the patients can be detected and invited to participate into the study. In both, the informed consent will be a prior and required procedure. The study will assess the outcomes in the same group of patients before and after intervention. The intervention follows the next steps: 1. Case detection: Identifying if the patient suffers from multiple diseases, if there are readmissions and high demand for health services during hospital stay or according to the reports of the health promoting entity (EPS in Spanish). 2. Case screening: assessing complexity INTERMED scale (European Consultation-Liaison Workgroup for General Hospital Psychiatry and Psychosomatic), medium-high or high). 3. To establish the baseline measurement of indicators to comparate during post-intervention. 4. Comprehensive and multidimensional assessment of the patient: identifying care needs. 5. Assessment of caregiver burden: identifying fatigue and general health status. 6. Personalized care plan: a comprehensive and individual plan is made for each case according to the needs detected. 7. Coordination between providers: contacts and procedures to secure referral to service providers as required by the patient and the family caregiver. 8. Monitoring and evaluation of the personalized plan.;Comprehensive Health Care;Patient Care Management;Long-Term Care;Delivery of Health Care ;Progressive Patient Care;Caregivers
Participant Information
Sponsor Health Sciences Universitary Foundation
City -
Country/Region Colombia
Enrollment Criteria
Sex Requirement ALL
Age Requirement -
Study Design
Study Type Interventional
Phase Not Available
Time Information
Start Date 2025-04-24
Primary Completion Date -
Completion Date -