Community Vascular and Multiple Chronic Conditions Intervention Study

Recruiting

Phase N/A Results N/A

Update History

2 Jul '16
Trial name was updated.
New
Community Vascular and Multiple Chronic Conditions Intervention Study
The Summary of Purpose was updated.
New
Patients with vascular and multiple chronic conditions (MCC) move between multiple care settings, and so they are at high risk of receiving fragmented care leading to increased risk for avoidable illness, death, and health care costs. Recent Canadian studies and reports identify significant gaps in the delivery of effective care to patients with multiple chronic conditions in community-based settings. The overall goal of the program is to promote successful management of chronic conditions, enhance quality of life, reduce the on-demand use of expensive health services and support primary caregivers (i.e. family or friends) who provide physical, emotional or financial care to an older adult with vascular conditions and MCC. This research program will leverage the tremendous potential to reduce the burden of vascular and vascular-related diseases by enhancing community-based prevention and chronic disease management. This pragmatic mixed-methods randomized controlled trial will evaluate the effectiveness of an interprofessional intervention on health-related quality of life (HRQOL), depression, anxiety, physical functioning, and the costs of use of health services for stroke survivors with MCC receiving home care and their family caregivers. The results will inform: (1) the development of national standards for community-based care for patients with multiple chronic conditions and (2) the development of a new and innovative community-based model for the management of multiple chronic conditions that can be scaled up and spread across Canada.
Old
Stroke survivors with multiple chronic conditions (MCC) move between multiple care settings, and so they are at high risk of receiving fragmented care leading to increased risk for avoidable illness, death, and health care costs. Recent Canadian studies and reports identify significant gaps in the delivery of effective stroke care to stroke survivors with multiple chronic conditions in community-based settings. Most stroke rehabilitation programs and guidelines are entirely focused on stroke only and do not address the challenges to patients and providers of managing comorbid conditions. This pragmatic mixed-methods randomized controlled trial will evaluate the effectiveness of a community navigation and rehabilitation intervention on health-related quality of life (HRQOL), depression, anxiety, community reintegration, number of strokes, physical functioning, and the costs of use of health services for stroke survivors with MCC receiving home care and their family caregivers. The results will inform: (1) the development of national standards for community-based stroke rehabilitation and (2) the development of a new and innovative community-based model for stroke rehabilitation that can be scaled up and spread across Canada.
The description was updated.
New
Research Question: What is the acceptability and effects of a six-month community navigation and management program compared to usual home care services for older adults with vascular conditions with MCC and their primary caregivers? Methods: The design is a pragmatic, mixed-methods; randomized controlled trial with individuals newly referred to home care services. The intervention is a 6-month community navigation and management program for patients with vascular conditions and multiple chronic conditions. It will be provided by an interprofessional team of home care providers and will consist of three components: (1) intensive case management to facilitate access to services across the care continuum, provide psychosocial support and advocacy, and coordinate home care; (2) a minimum of two in-home visits by the Community Care Access Centre (CCAC) Case Manager, two visits by the Registered Nurse (RN), three visits by the physiotherapist (PT) or occupational therapist (OT), and six visits by a Personal Support Worker (PSW) over 6 months in addition to usual home care services. The in-home visit schedule and team composition will be tailored to client need and will be determined in collaboration with the home care providers. The interprofessional (IP) team will conduct comprehensive screening and assessments for chronic conditions, utilize strengths-based practice to encourage self-care and foster behavioural change, provide education for multiple chronic conditions, medication review, in-home exercise, and caregiver support; and (3) monthly interprofessional team case conferences to develop an IP evidence-based, patient-centred care plan. Outcomes will be assessed at baseline and 6 months. Summary descriptive measures will be reported for all variables. Analysis of covariance will be used to compare study groups, while adjusting for baseline measurements and potential confounding variables. Subgroup analyses will be conducted based on sex/gender and region. Expected Outcomes: It is expected that patients with vascular conditions and multiple chronic conditions receiving the intervention will show greater improvements in health-related quality of life, at no additional cost, compared with usual care.
Old
Research Questions: 1. Does a 6-month community navigation and rehabilitation intervention improve health-related quality of life, compared with usual home care services? 2. What is the effectiveness of the intervention on depression, anxiety, physical functioning, community reintegration, and costs of use of health services from a societal perspective? 3. What is the effectiveness of the intervention on the HRQoL of family caregivers? 4. Does the intervention improve clinical practice behaviours and team collaboration? 5. Which subgroups of stroke survivors with MCC benefit most from the intervention (e.g., based on sex/gender, age, income etc.)? Methods: The design is a pragmatic, multisite, mixed-methods; randomized controlled trial with individuals newly referred to home care services. The intervention is a 6-month multifaceted and evidence-based rehabilitation strategy. It will be provided by an interprofessional team of home care providers and will consist of three components: (1) intensive case management and community navigation to facilitate access to services across the care continuum, provide psychosocial support and advocacy, and coordinate home care; (2) a minimum of two in-home visits by the Community Care Access Centre (CCAC) Case Manager, two visits by the Registered Nurse (RN), three visits by the physiotherapist (PT) or occupational therapist (OT), and six visits by a Personal Support Worker (PSW) over 6 months in addition to usual home care services. The in-home visit schedule and team composition will be tailored to client need and will be determined in collaboration with the home care providers. The interprofessional (IP) team will conduct comprehensive screening and assessment and modify risk factors for stroke, stroke-related complications, and other chronic conditions, utilize strengths-based practice to encourage self-care and foster behavioural change, provide stroke education, medication review, in-home exercise, and caregiver support; and (3) monthly interprofessional team case conferences to develop an IP evidence-based, patient-centred community reintegration plan. Outcomes will be assessed at baseline and 6 months. Summary descriptive measures will be reported for all variables. Analysis of covariance will be used to compare study groups, while adjusting for baseline measurements and potential confounding variables. Subgroup analyses will be conducted based on sex/gender and region. Expected Outcomes: It is expected that stroke survivors with multiple chronic conditions receiving the intervention will show greater improvements in health-related quality of life, at no additional cost, compared with usual care.
The eligibility criteria were updated.
New
Inclusion Criteria: - 65 years of age and older; - One of the four vascular conditions: Stroke and TIA, Hypertension, Cardiovascular disease and Heart failure - Newly referred (following initiation of the study) for home care services and living in the community, including supportive housing, retirement homes, and lodging homes and excluding long-term care; - At least 1 comorbid conditions; - Able to speak English or have access to a translator; - Not planning to move away from the CCAC catchment area in the next 6 months; - Be mentally competent to provide informed consent, either independently or by a substitute decision maker. Exclusion Criteria: - Participants will be excluded if they are unable to read and understand English and do not have access to their own translator
Old
Inclusion Criteria: - 65 years or older - newly referred to for home care services and living in the community, including supportive housing, retirement homes and lodging homes, excluding long-term care - have a confirmed diagnosis of stroke (first-ever or recurrent) in the previous 12 months - have at least two comorbid conditions - not planning to move away from the CCAC catchment area in the next 6 months Exclusion Criteria: - Participants will be excluded if they are unable to read and understand English and do not have access to their own translator
5 Apr '16
The Summary of Purpose was updated.
New
Stroke survivors with multiple chronic conditions (MCC) move between multiple care settings, and so they are at high risk of receiving fragmented care leading to increased risk for avoidable illness, death, and health care costs. Recent Canadian studies and reports identify significant gaps in the delivery of effective stroke care to stroke survivors with multiple chronic conditions in community-based settings. Most stroke rehabilitation programs and guidelines are entirely focused on stroke only and do not address the challenges to patients and providers of managing comorbid conditions. This pragmatic mixed-methods randomized controlled trial will evaluate the effectiveness of a community navigation and rehabilitation intervention on health-related quality of life (HRQOL), depression, anxiety, community reintegration, number of strokes, physical functioning, and the costs of use of health services for stroke survivors with MCC receiving home care and their family caregivers. The results will inform: (1) the development of national standards for community-based stroke rehabilitation and (2) the development of a new and innovative community-based model for stroke rehabilitation that can be scaled up and spread across Canada.
Old
Stroke survivors with multiple chronic conditions (MCC) move between multiple care settings, and so they are at high risk of receiving fragmented care leading to increased risk for avoidable illness, death, and health care costs. Recent Canadian studies and reports identify significant gaps in the delivery of effective stroke care to stroke survivors with multiple chronic conditions in community-based settings. Most stroke rehabilitation programs and guidelines are entirely focused on stroke only and do not address the challenges to patients and providers of managing comorbid conditions. This pragmatic mixed-methods randomized controlled trial will evaluate the effectiveness of a community navigation and rehabilitation intervention on health-related quality of life (HRQOL), depression, anxiety, community reintegration, number of strokes, physical functioning, and the costs of use of health services for stroke survivors with MCC receiving home care and their family caregivers. The results will inform: (1) the development of national standards for community-based stroke rehabilitation and (2) the development of a new and innovative community-based model for stroke rehabilitation that can be scaled up and spread across Canada.
A location was updated in Hamilton.
New
The overall status was updated to "Recruiting" at McMaster University.
6 May '15
The description was updated.
New
Research Questions: 1. Does a 6-month community navigation and rehabilitation intervention improve health-related quality of life, compared with usual home care services? 2. What is the effectiveness of the intervention on depression, anxiety, physical functioning, community reintegration, and costs of use of health services from a societal perspective? 3. What is the effectiveness of the intervention on the HRQoL of family caregivers? 4. Does the intervention improve clinical practice behaviours and team collaboration? 5. Which subgroups of stroke survivors with MCC benefit most from the intervention (e.g., based on sex/gender, age, income etc.)? Methods: The design is a pragmatic, multisite, mixed-methods; randomized controlled trial with individuals newly referred to home care services. The intervention is a 6-month multifaceted and evidence-based rehabilitation strategy. It will be provided by an interprofessional team of home care providers and will consist of three components: (1) intensive case management and community navigation to facilitate access to services across the care continuum, provide psychosocial support and advocacy, and coordinate home care; (2) a minimum of two in-home visits by the Community Care Access Centre (CCAC) Case Manager, two visits by the Registered Nurse (RN), three visits by the physiotherapist (PT) or occupational therapist (OT), and six visits by a Personal Support Worker (PSW) over 6 months in addition to usual home care services. The in-home visit schedule and team composition will be tailored to client need and will be determined in collaboration with the home care providers. The interprofessional (IP) team will conduct comprehensive screening and assessment and modify risk factors for stroke, stroke-related complications, and other chronic conditions, utilize strengths-based practice to encourage self-care and foster behavioural change, provide stroke education, medication review, in-home exercise, and caregiver support; and (3) monthly interprofessional team case conferences to develop an IP evidence-based, patient-centred community reintegration plan. Outcomes will be assessed at baseline and 6 months. Summary descriptive measures will be reported for all variables. Analysis of covariance will be used to compare study groups, while adjusting for baseline measurements and potential confounding variables. Subgroup analyses will be conducted based on sex/gender and region. Expected Outcomes: It is expected that stroke survivors with multiple chronic conditions receiving the intervention will show greater improvements in health-related quality of life, at no additional cost, compared with usual care.
Old
Research Questions: 1. Does a 6-month community navigation and rehabilitation intervention improve health-related quality of life, compared with usual home care services? 2. What is the effectiveness of the intervention on depression, anxiety, physical functioning, community reintegration, and costs of use of health services from a societal perspective? 3. What is the effectiveness of the intervention on the HRQoL of family caregivers? 4. Does the intervention improve clinical practice behaviours and team collaboration? 5. Which subgroups of stroke survivors with MCC benefit most from the intervention (e.g., based on sex/gender, age, income etc.)? Methods: The design is a pragmatic, multisite, mixed-methods; randomized controlled trial with individuals newly referred to home care services. The intervention is a 6-month multifaceted and evidence-based rehabilitation strategy. It will be provided by an interprofessional team of home care providers and will consist of three components: (1) intensive case management and community navigation to facilitate access to services across the care continuum, provide psychosocial support and advocacy, and coordinate home care; (2) a minimum of two in-home visits by the Community Care Access Centre (CCAC) Case Manager, two visits by the Registered Nurse (RN), three visits by the physiotherapist (PT) or occupational therapist (OT) over 6 months in addition to usual home care services. Personal support worker visits will follow a usual care schedule. The in-home visit schedule and team composition will be tailored to client need and will be determined in collaboration with the home care providers. The interprofessional (IP) team will conduct comprehensive screening and assessment and modify risk factors for stroke, stroke-related complications, and other chronic conditions, utilize strengths-based practice to encourage self-care and foster behavioural change, provide stroke education, medication review, in-home exercise, and caregiver support; and (3) monthly interprofessional team case conferences to develop an IP evidence-based, patient-centred community reintegration plan. Outcomes will be assessed at baseline and 6 months. Summary descriptive measures will be reported for all variables. Analysis of covariance will be used to compare study groups, while adjusting for baseline measurements and potential confounding variables. Subgroup analyses will be conducted based on sex/gender and region. Expected Outcomes: It is expected that stroke survivors with multiple chronic conditions receiving the intervention will show greater improvements in health-related quality of life, at no additional cost, compared with usual care.
28 Feb '15
The Summary of Purpose was updated.
New
Stroke survivors with multiple chronic conditions (MCC) move between multiple care settings, and so they are at high risk of receiving fragmented care leading to increased risk for avoidable illness, death, and health care costs. Recent Canadian studies and reports identify significant gaps in the delivery of effective stroke care to stroke survivors with multiple chronic conditions in community-based settings. Most stroke rehabilitation programs and guidelines are entirely focused on stroke only and do not address the challenges to patients and providers of managing comorbid conditions. This pragmatic mixed-methods randomized controlled trial will evaluate the effectiveness of a community navigation and rehabilitation intervention on health-related quality of life (HRQOL), depression, anxiety, community reintegration, number of strokes, physical functioning, and the costs of use of health services for stroke survivors with MCC receiving home care and their family caregivers. The results will inform: (1) the development of national standards for community-based stroke rehabilitation and (2) the development of a new and innovative community-based model for stroke rehabilitation that can be scaled up and spread across Canada.
Old
Stroke survivors with multiple chronic conditions (MCC) move between multiple care settings, and so they are at high risk of receiving fragmented care leading to increased risk for avoidable illness, death, and health care costs. Recent Canadian studies and reports identify significant gaps in the delivery of effective stroke care to stroke survivors with multiple chronic conditions in community-based settings. Most stroke rehabilitation programs and guidelines are entirely focused on stroke only and do not address the challenges to patients and providers of managing comorbid conditions. This pragmatic mixed methods randomized controlled trial will evaluate the effectiveness of a community navigation and rehabilitation intervention on health-related quality of life (HRQOL), depression, anxiety, community reintegration, number of strokes, physical functioning, and the costs of use of health services for stroke survivors with MCC receiving home care and their family caregivers. The results will inform: (1) the development of national standards for community-based stroke rehabilitation and (2) the development of a new and innovative community-based model for stroke rehabilitation that can be adapted and implemented for stroke survivors with MCC across Canada.
The description was updated.
New
Research Questions: 1. Does a 6-month community navigation and rehabilitation intervention improve health-related quality of life, compared with usual home care services? 2. What is the effectiveness of the intervention on depression, anxiety, physical functioning, community reintegration, and costs of use of health services from a societal perspective? 3. What is the effectiveness of the intervention on the HRQoL of family caregivers? 4. Does the intervention improve clinical practice behaviours and team collaboration? 5. Which subgroups of stroke survivors with MCC benefit most from the intervention (e.g., based on sex/gender, age, income etc.)? Methods: The design is a pragmatic, multisite, mixed-methods; randomized controlled trial with individuals newly referred to home care services. The intervention is a 6-month multifaceted and evidence-based rehabilitation strategy. It will be provided by an interprofessional team of home care providers and will consist of three components: (1) intensive case management and community navigation to facilitate access to services across the care continuum, provide psychosocial support and advocacy, and coordinate home care; (2) a minimum of two in-home visits by the Community Care Access Centre (CCAC) Case Manager, two visits by the Registered Nurse (RN), three visits by the physiotherapist (PT) or occupational therapist (OT) over 6 months in addition to usual home care services. Personal support worker visits will follow a usual care schedule. The in-home visit schedule and team composition will be tailored to client need and will be determined in collaboration with the home care providers. The interprofessional (IP) team will conduct comprehensive screening and assessment and modify risk factors for stroke, stroke-related complications, and other chronic conditions, utilize strengths-based practice to encourage self-care and foster behavioural change, provide stroke education, medication review, in-home exercise, and caregiver support; and (3) monthly interprofessional team case conferences to develop an IP evidence-based, patient-centred community reintegration plan. Outcomes will be assessed at baseline and 6 months. Summary descriptive measures will be reported for all variables. Analysis of covariance will be used to compare study groups, while adjusting for baseline measurements and potential confounding variables. Subgroup analyses will be conducted based on sex/gender and region. Expected Outcomes: It is expected that stroke survivors with multiple chronic conditions receiving the intervention will show greater improvements in health-related quality of life, at no additional cost, compared with usual care.
Old
Research Questions: 1. Does a 6-month community navigation and rehabilitation intervention improve health-related quality of life, compared with usual home care services? 2. What is the effectiveness of the intervention on depression, anxiety, physical functioning, number of falls, fall risk, medication safety, community reintegration, number of vascular events, and costs of use of health services? 3. What is the effectiveness of the intervention on HRQoL of family caregivers? 4. Does the intervention improve clinical practice behaviours? 5. Which subgroups of stroke survivors with MCC benefit most from the intervention (e.g., based on sex/gender, age, income etc.)? Methods: The design is a pragmatic, multisite, mixed-methods, randomized controlled trial with individuals newly referred to home care services. The intervention is a 6-month multifaceted and evidence-based rehabilitation strategy. It will be provided by an integrated interprofessional team of home care providers and will consist of three components: (1) intensive case management and community navigation to facilitate access to services across the care continuum, provide psychosocial support and advocacy, and coordinate home care; (2) a minimum of three in-home visits by the Community Care Access Centre (CCAC) Case Manager, three visits by the Registered Nurse (RN), four visits by the physiotherapist (PT) or occupational therapist (OT), and four hours of care by a personal support worker (PSW) over 6 months in addition to usual home care services. The interprofessional (IP) team will conduct comprehensive screening and assessment and modify risk factors for stroke, stroke-related complications, and other chronic conditions, utilize strengths-based practice to encourage self-care and foster behavioural change, provide stroke education, medication review, in-home exercise, and caregiver support; and (3) monthly interprofessional team conferences to develop an IP evidence-based, patient-centred community reintegration plan. Outcomes will be assessed at baseline and 6 months. Summary descriptive measures will be reported for all variables. Analysis of covariance will be used to compare study groups, while adjusting for baseline measurements and potential confounding variables. Subgroup analyses will be conducted based on sex/gender and region. Expected Outcomes: It is expected that stroke survivors with multiple chronic conditions receiving the intervention will show greater improvements in health-related quality of life, at no additional cost, compared with usual care.
The eligibility criteria were updated.
New
Inclusion Criteria: - 65 years or older - newly referred to for home care services and living in the community, including supportive housing, retirement homes and lodging homes, excluding long-term care - have a confirmed diagnosis of stroke (first-ever or recurrent) in the previous 12 months - have at least two comorbid conditions - not planning to move away from the CCAC catchment area in the next 6 months Exclusion Criteria: - Participants will be excluded if they are unable to read and understand English and do not have access to their own translator
Old
Inclusion Criteria: - 65 years or older - newly referred to home care services - have a confirmed diagnosis of stroke (first-ever or recurrent) in the previous 18 months - have at least two comorbid conditions Exclusion Criteria: - Participants will be excluded if they are unable to read and understand English