Enhancing Community Health Through Patient Navigation, Advocacy and Social Support "ENCOMPASS"

Not yet recruiting

Phase N/A Results N/A

Eligibility Criteria

Inclusion Criteria

≥ 18 years of age with two or more of the following, as identified in the clinic EMR:
(i) Poorly controlled hypertension (most recent systolic blood pressure > 160 mmHg); (ii) Poorly controlled diabetes (A1C > 9% on at least one occasion within the past year); (iii) Stage 3b or greater chronic kidney disease (estimated glomerular filtration rate < 45 mL/min/1.73m2 in past year); (iv) Established ischemic heart disease (at least one instance of a physician billing diagnosis with a relevant International Classification of Diseases, 9th Edition [ICD-9] code recorded in EMR); (v) Congestive heart failure (at least one instance of a physician billing diagnosis with a relevant ICD-9 code recorded in EMR); (vi) Chronic obstructive pulmonary disease OR Asthma with at least two visits in the past year (at least 2 instances of a physician billing diagnosis with a relevant ICD-9 code).

Exclusion Criteria

i) patient unable to provide informed consent; ii) patient residing in a long-term care facility; iii) physician discretion