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Enhanced Care Planning for Multiple Chronic Conditions

N/A

Recruiting

Led By Alex H Krist, MD MPH

Research Sponsored by Virginia Commonwealth University

Eligibility Criteria Checklist

Specific guidelines that determine who can or cannot participate in a clinical trial

Must have

At least one uncontrolled condition

Be older than 18 years old

Timeline

Screening 3 weeks

Treatment Varies

Follow Up 6 months after creating a care plan

Awards & highlights

Study Summary

This trial is investigating whether an enhanced care planning approach, paired with community-clinical linkages support, can help address health behavior, mental health, and social needs for patients with multiple chronic conditions.

Who is the study for?

This trial is for individuals with at least one uncontrolled condition and two or more chronic conditions who have completed a baseline survey. It's not open to those already in the Richmond Accountable Health Community study or excluded by their clinician.Check my eligibility

What is being tested?

The trial tests an enhanced care planning approach that includes behavioral, mental health, and social support, comparing it to usual care in patients with multiple chronic conditions within a randomized controlled setting.See study design

What are the potential side effects?

Since this intervention involves care planning rather than medication, traditional side effects are not expected; however, there may be indirect effects on patient well-being based on the changes in care management.

Eligibility Criteria

Inclusion Criteria

You may be eligible if you check “Yes” for the criteria below

Select...

I have a health condition that is not currently under control.

Timeline

Screening ~ 3 weeks3 visits

Treatment ~ Varies

Follow Up ~ within 6 months of enrollment

Screening ~ 3 weeks

Treatment ~ Varies

Follow Up ~within 6 months of enrollment

This trial's timeline: 3 weeks for screening, Varies for treatment, and within 6 months of enrollment for reporting.

Treatment Details

Study Objectives

Outcome measures can provide a clearer picture of what you can expect from a treatment.

Primary outcome measures

Effectiveness - chronic condition control

Effectiveness - quality of life: Patient Reported Outcomes Measurement Information System (PROMIS-29)

Enhanced care plan creation (implementation outcome)

+4 more

Trial Design

2Treatment groups

Experimental Treatment

Active Control

Group I: Enhanced care planningExperimental Treatment1 Intervention

The intervention consists of two components - enhanced care planning and clinical-community linkages. The enhanced care plan is created using MOHR (https://myownhealthreport.org). MOHR screens patients for unhealthy behaviors, mental health needs, and social needs. Patients identify the needs they would like to address and create a care plan, which they update quarterly. A clinical navigator and community health worker (CHW) help patients address their care plans using clinical-community linkages, which has four components. First, clinicians and clinical navigators have a resource registry identifying community programs and support - No Wrong Door (NWD) and https://navigator.aafp.org/. Second, MOHR shares information (care plans, patient narrative, and patient progress) across clinical and community team members. Third, MOHR supports messaging and video visits for team members and patients. Finally, MOHR sends care team members quarterly patient progress updates.

Group II: Usual medical careActive Control1 Intervention

Clinicians randomized to the control condition will continue to provide "usual care." This includes current non-systematic assessment of health behaviors, mental health needs, and social needs. Neither clinicians nor patients will be eligible to receive CHW support or have access to NWD. Clinicians may refer some control patients to community programs as part of their current usual care. Control clinicians will be blinded as to which patients are included in the study. At the end of the study, the investigators will share with control clinicians our lessons learned, access to MOHR, and lists of useful community resources.

0 / 1Eligibility criteria met

Find a Location

Who is running the clinical trial?

Agency for Healthcare Research and Quality (AHRQ)FED

399 Previous Clinical Trials

6,821,748 Total Patients Enrolled

1 Trials studying Multiple Chronic Conditions

798 Patients Enrolled for Multiple Chronic Conditions

Virginia Commonwealth UniversityLead Sponsor

698 Previous Clinical Trials

22,884,395 Total Patients Enrolled

Alex H Krist, MD MPHPrincipal InvestigatorVirginia Commonwealth University

2 Previous Clinical Trials

9,091 Total Patients Enrolled

Media Library

Multiple Chronic Conditions Research Study Groups: Enhanced care planning, Usual medical care

Multiple Chronic Conditions Clinical Trial 2023: Enhanced care planning Highlights & Side Effects. Trial Name: NCT03885401 — N/A

Enhanced care planning 2023 Treatment Timeline for Medical Study. Trial Name: NCT03885401 — N/A

Frequently Asked Questions

These questions and answers are submitted by anonymous patients, and have not been verified by our internal team.

How many participants have registered for this clinical examination?

"Affirmative. Clinicaltrials.gov shows that the trial, which was initially listed on September 20th 2020, is currently recruiting participants. Around 600 people are needed for this study at a single location."

Answered by AI

Are there vacancies for individuals to join this experiment?

"According to the latest data on clinicaltrials.gov, this trial is still recruiting patients for participation. It was initially published September 20th 2020 and its details have been revised as recently as October 3rd 2022."

Answered by AI

Are individuals of all ages eligible to participate in this testing program?

"This clinical trial is exclusively for patients between the ages of 18 to 99. However, there are alternative studies available that accommodate younger and elder individuals at 295 and 723 trials respectively."

Answered by AI

Is there a possibility for me to join this research endeavor?

"This medical study is seeking 600 individuals between 18 and 99 with mental health issues. Successful applicants must demonstrate an uncontrolled condition as well as two or more chronic diseases."

Answered by AI

Recent research and studies

TrialsJournal

Enhanced Care Planning and Clinical-community Linkages Versus Usual Care to Address Basic Needs of Patients with Multiple Chronic Conditions: A Clinician-level Randomized Controlled Trial

Krist, Alex H., Kristen O’Loughlin, Steven H. Woolf, Roy T. Sabo, Jennifer Hinesley, Anton J. Kuzel, Bruce D. Rybarczyk, et al.. 2020. “Enhanced Care Planning and Clinical-community Linkages Versus Usual Care to Address Basic Needs of Patients with Multiple Chronic Conditions: A Clinician-level Randomized Controlled Trial”. Trials. Springer Science and Business Media LLC. doi:10.1186/s13063-020-04463-3.

clinicaltrials.govStudy

Enhanced Care Planning for Patients With Multiple Chronic Conditions

2020. "Enhanced Care Planning for Patients With Multiple Chronic Conditions". ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT03885401.