Pursuing the Triple Aim in Hotspotters: Identification and Integrated Care (NCT05878054) | Clinical Trial Compass
Active — Not RecruitingNot Applicable
Pursuing the Triple Aim in Hotspotters: Identification and Integrated Care
Netherlands41 participantsStarted 2023-08-02
Plain-language summary
Hotspotters are patients with complex care needs, defined by problems in multiple life domains and high acute care use. These patients often receive mismatched care, resulting in overuse of care and increased healthcare costs. Reliable data on (cost-)effective interventions for these patients are scarce. The goal of this study is to assess the cost-effectiveness of pro-active and integrated care. This approach includes: an intake consultation with Positive Health; multidisciplinary meetings with physician, mental healthcare nurse, social worker and the patient; a personalised care plan and proactive care management. We aim to include 200 patients, divided over 20 primary care practices.
Who can participate
Age range18 Years
SexALL
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Inclusion Criteria:
* The patients are ≥ 18yrs
* The patients are registered within one of the participating GP practices.
* Patients with at least two acute care encounters in the past 12 months. Acute care encounter is defined as an encounter with out-of-hours GP service, emergency care or acute mental health care.Patients have problems registered in the GP Information system on at least two out of three of the following domains: somatic, mental or social. Somatic problems is having at least one ICPC code on the problem list. Mental problems is having at least one ICPC code from the "P"-chapter on either the problem list, as a reason for encounter, and/or having medication prescribed related to mental health problems. Social problems is having at least one ICPC code from the "Z"-chapter or as reason for encounter, and/or having medication prescribed related to social problems.
Exclusion Criteria:
* The patient is terminal.
* The patient is living in a residential home.
* The patient has dementia or a disability that prevents them from communicating effectively.The patient already has experience with the positive health tool.
* The patient is not competent to make decisions concerning their health. This wil be assessed by the patient's own general practitioner.
* Veto of the GP