Comprehensive-Care for Multimorbid Adults Effectiveness Study (CCMAP)
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ClinicalTrials.gov Identifier: NCT01811173 |
Recruitment Status : Unknown
Verified February 2013 by Meir Medical Center.
Recruitment status was: Active, not recruiting
First Posted : March 14, 2013
Last Update Posted : April 29, 2015
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Condition or disease | Intervention/treatment | Phase |
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Chronic Disease | Other: Nurse-physician comprehensive care | Not Applicable |
Patients with multi-morbidities pose a significant challenge for healthcare organizations because they require continuity of care among a wide range of long-term therapeutic paradigms for many different types of diseases. The current study is based on a treatment model entailing a nurse-primary care physician team to provide care for patients with multiple morbidities.
Patients in the intervention group who agreed and signed the consent form to participate in the study will receive treatment by the physician - nurse team in accordance with the components of the Clalit's Comprehensive Care for Mutlimorbid Adults Project model. Components of the intervention include:
- Comprehensive assessment of the patient's and family's needs
- Coordinated care plan based on integrated care guides
- "Multimorbid Action Plan" for patients
- All-inclussive patient centered care and caregiver support
- Proactive monitoring according to the plan.
Patients in the control groups will receive usual care in their primary care clinics. The Usual Care Survey control group will complete study questionnaires at 6, 12 and 24 months after enrollement.
The Usual Care Blinded group will be assessed only retrospectively based on deidentified information from Clalit's admistrative databases.
Study Type : | Interventional (Clinical Trial) |
Estimated Enrollment : | 1800 participants |
Allocation: | Non-Randomized |
Intervention Model: | Parallel Assignment |
Masking: | None (Open Label) |
Primary Purpose: | Health Services Research |
Official Title: | The Clalit Comprehensive-Care for Multimorbid Adults Project |
Study Start Date : | March 2013 |
Estimated Primary Completion Date : | March 2017 |
Estimated Study Completion Date : | March 2017 |

Arm | Intervention/treatment |
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Experimental: Nurse-physician comprehensive care
Comprehensive self management support and care coordination by a nurse-primary care physician team
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Other: Nurse-physician comprehensive care
Components of the intervention include:
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No Intervention: Usual care survey control group
Patients will receive usual primary care and asked to complete questionnaires on four time points throughout the study
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No Intervention: Usual care blinded control group
Patients will receive usual primary care.
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- Percent change in admissions for ambulatory care sensetive conditions [ Time Frame: At enrollment and within 12 months and 24 months after enrollment ]Ambulatory Care Sensitive Conditions will be defined by ICD-9 codes, based on the classification published by: Ansari, Barbetti, Carson, Auckland, & Cicuttini, 2003 (adapted from Weissman JS, Gatsonis C, Epstein AM ,1992; Millman M, ed. 1993)
- Emergency 30-day readmissions [ Time Frame: 30 days post an index admission ]Emergency readmissions are defined as an urgent (via the Emergency Room) admission of one night or longer, following an index admission that lasted 2 nights or longer, in the prior 30 days.
- Change in SF-12 Physical and Menal component scores [ Time Frame: At enrollment and 6, 12, and 24 months after enrollment ]Change in Physical and Menal Component scores of the SF-12 measure, as completed by patients through patient interviews

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Ages Eligible for Study: | 18 Years to 95 Years (Adult, Older Adult) |
Sexes Eligible for Study: | All |
Accepts Healthy Volunteers: | No |
Inclusion Criteria:
- ACG system high risk probabilty score - 4% Highest Risk Score
- Age 18 and older
- 2 or more chronic conditions
Exclusion Criteria:
- Patients already included in a controlled disease management program (e.g., COPD disease management and telehealth).
- Participation in any medical research.
- Confined to bed.
- Inpatient nursing care, nursing homes.
- Kidney, liver or heart transplant patients.
- Active (receipt of oncology chemotherapy , radiotherapy or other oncology treatment during the past 3 years).
- Dialysis patients.
- Clalit Healthcare Services employees.
- Patients with major active mental illness, such as schizophrenia.
- Cognitive failure.
- Non Hebrew speaking patients without Hebrew speaking primary informal caregiver.
- Bedridden patients
- Housebound patients

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.
Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT01811173
Israel | |
Ashdod A | |
Ashdod, Israel | |
Ashdod D | |
Ashdod, Israel | |
Azur | |
Azur, Israel | |
Arlozorov | |
Bat YAm, Israel | |
Hashikma | |
Bat Yam, Israel | |
Ramat Yosef | |
Bat Yam, Israel | |
Sokolov | |
Bat Yam, Israel | |
Halutz | |
Hulon, Israel | |
Shikun Ammi | |
Hulon, Israel | |
Lod Center | |
Lod, Israel | |
Ramla Ztafon | |
Ramla, Israel | |
Balfur | |
Rishon Lezion, Israel | |
Migdal HaIr | |
Rishon Lezion, Israel |
Principal Investigator: | Ran D Balicer, PhD | Clalit Research Institute, Clalit Health Services |
Responsible Party: | Meir Medical Center |
ClinicalTrials.gov Identifier: | NCT01811173 |
Other Study ID Numbers: |
CCMAP |
First Posted: | March 14, 2013 Key Record Dates |
Last Update Posted: | April 29, 2015 |
Last Verified: | February 2013 |
multimorbidity primary care physician - nurse team |
proactive monitoring support for self-care primary caregiver |
Chronic Disease Disease Attributes Pathologic Processes |