Community Health Worker Intervention for Patients With Complex Chronic Disease

Not yet recruiting

Phase N/A Results N/A

Trial Description

In Canada, the prevalence of chronic disease is increasing and patients presenting with multiple conditions (i.e., multimorbidity) are becoming the norm in primary care. Complex treatment regimens such as administration of medications (including insulin), clinical monitoring and screening for complications, adherence to dietary and lifestyle changes, and decisions about when to seek medical care are challenging. To help people with complex health conditions optimize their care and outcomes, community health worker programs have begun to be used across the United States and Canada. Existing community health worker programs share a common goal of helping patients to overcome modifiable barriers to care to achieve optimal outcomes.
While community health workers may work within a primary health care team, the primary role of the community health worker is not clinically oriented, and may be fulfilled by laypersons. Depending on the targeted barriers, specific tasks may include one or more of: disease education, health system education, assistance with insurance coverage, aid in care coordination, and referral to community resources, among others. Herein, the investigators aim to evaluate the effectiveness of a community health worker intervention on improving acute care utilization among patients with complex chronic disease seen in primary care.

Detailed Description

Chronic diseases are long--term conditions that progress in severity over time and are generally not curable. Results from the Canadian Community Health Survey (CCHS) indicate that approximately 21% of adults over 20 years had at least one major chronic disease. Among these, approximately 10% had diabetes, 6% had cardiovascular disease, 4% had heart failure, and 10% had asthma and chronic obstructive pulmonary disorder, reported by the Canadian Chronic Disease Surveillance System. In 2012-13, over 735,000 Albertans had at least one major chronic disease, and publicly funded health services for these patients cost the Alberta government approximately $4.5 billion dollars in that year.
In Canada, the prevalence of chronic disease is increasing and patients presenting with multiple conditions (i.e., multimorbidity) are becoming the norm in primary care. Multimorbidity is associated with poor quality of life, decline in functional status, and a high burden on the healthcare system. Safe, efficacious and cost--effective interventions for chronic diseases are available, however these treatments are under-utilized. Individuals with chronic diseases may have difficulty achieving care goals due to a combination of patient, provider and system level barriers. Complex treatment regimens such as administration of medications (including insulin), clinical monitoring and screening for complications, adherence to dietary and lifestyle changes, and decisions about when to seek medical care are challenging. The ability to comply with these recommendations is dependent on a number of factors, including health and financial status, access to care and care experience, and personal circumstance.
To help people with complex health conditions optimize their care and outcomes, community health worker programs have begun to be used across the United States and Canada. Existing community health worker programs share a common goal of helping patients to overcome modifiable barriers to care to achieve optimal outcomes, and are a possible solution to overcoming barriers to accessing health care in patients with complex chronic disease.
While community health workers may work within a primary health care team, the primary role of the community health worker is not clinically oriented, and may be fulfilled by laypersons. Depending on the targeted barriers, specific tasks may include one or more of: disease education, health system education, assistance with insurance coverage, aid in care coordination, and referral to community resources, among others. Herein, the investigators propose a trial to evaluate the effectiveness of a community health worker intervention on improving acute care utilization among patients with complex chronic disease seen in primary care.

Conditions

Interventions

  • Community Health Worker Intervention Behavioral
    Intervention Desc: Patients will be matched to a CHW from their primary care practice. The CHW will conduct a needs assessment to determine the intensity of intervention and frequency of meetings needed. A CHW may perform any of the following: providing information directly to a patient's health care provider, translating to the patient's language, advocating for the patient, connecting the patient with resources (i.e., social, financial, insurance), helping patients set health--related goals, liaising with a patient's employer to make sure the patient's health needs are met, facilitating health care referrals and appointments, monitoring appointments, and facilitating transportation to appointments. These activities may require the CHW to be physically present at the patient's appointments or have direct contact with the patient's health care provider. Goal setting and social support will be provided in- person or over the telephone using motivational interviewing (MI) principles.
    ARM 1: Kind: Experimental
    Label: Community Health Worker Intervention
    Description: Patients enrolled in the intervention will be matched to a Community Health Worker (CHW) from their primary care practice. Based on an initial needs assessment, patients receiving the intervention will have support from a CHW with any of the following: scheduling appointments, language interpretation, obtaining financial and social resources, filling out forms, health system navigation, transportation facilitation, barrier identification, patient advocacy, understanding of treatment plans and communication with health care providers.

Outcomes

Type Measure Time Frame Safety Issue
Primary Acute care utilization Up to 36 months
Secondary Cardiovascular disease risk 6 months prior to receiving intervention to 6 months post-intervention
Secondary Health-related quality of life 6 months prior to receiving intervention to 6 months post-intervention
Secondary Disease-specific intermediate health outcomes Up to 36 months
Secondary Disease-specific intermediate health outcome- Diabetes Up to 36 months
Secondary Disease-specific intermediate health outcomes- Chronic kidney disease Up to 36 months
Secondary Disease-specific intermediate health outcomes- Myocardial Infarction, stroke, Peripheral Vascular Disease, Coronary Artery Disease, Coronary Heart Failure Up to 36 months
Secondary Disease-specific intermediate health outcomes- Chronic obstructive pulmonary disease, asthma Up to 36 months
Secondary Patient activation 6 months prior to receiving intervention to 6 months post-intervention
Secondary Patient experience with chronic illness care 6 months prior to receiving intervention to 6 months post-intervention
Secondary Primary care attachment Up to 36 months
Secondary Physician experience 6 months post-intervention
Secondary Medication adherence Up to 36 months
Secondary Mortality Up to 36 months

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