Community Health Worker Intervention for Patients With Complex Chronic Disease

Not yet recruiting

Phase N/A Results N/A

Eligibility Criteria

Inclusion Criteria

- Any two of the following:
1. Diabetes (A1C > 9%)
2. Chronic kidney disease (eGFR <30 or eGFR <60+albuminuria)
3. Established cardiovascular disease (history of MI, stroke, CAD, PVD, CHF)
4. Chronic obstructive pulmonary disorder (history of COPD)
5. Severe asthma (Hx+ presence of >1 unique inhalers)
6. High cardiometabolic risk (Diabetes + Hypertension + High cholesterol OR smoking status + diabetes or hypertension)

Exclusion Criteria

- Moderate to severe dementia.
- Inability to provide informed consent.
- Resides in nursing home
- Physician discretion