The purpose of this study is to evaluate whether a new model of health care for chronic patients, based on Case Management and guided by a nurse which targets the patient´s risk, is more effective than usual care at Primary Health care in Chile. Additionally, this intervention would provide a better quality of care and a more efficient health provision.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
SINGLE
Enrollment
616
A model of health care for chronic patients, based on Case Management and guided by a nurse which targets the patient´s risk. The core elements of this strategy are: a. processes to identify specific population and their risk; b. evidence-based practice guidelines according to risk (higher risk, more interventions and monitoring by a nurse, lower risk, higher emphasis on self-care); c. Practice models based on collaboration between health team members leaded by a nurse; d. self-management education for patients; e. monitoring patients face to face or by telephone to ensure to follow the care program (blood test, medical consultation, for example); e. measurement of process and outcomes.
Usual Care at Primary Health Care Center
CESFAM La Faena
Peñalolén, RM, Chile
Glycated Hemoglobin
Time frame: One year
Systolic and Diastolic Blood Pressure
Time frame: One year
Quality of Care
Measured by Clinical records audits
Time frame: one year
Patient satisfaction
Measured by a questionnaire
Time frame: one year
Medication adherence
Measured by Morisky- Green questionnaire
Time frame: one year
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