Vulnerable Patients in Primary Care: Nurse Case Management and Self-management Support
Condition: Chronic Diseases
MeSH terms: Chronic Disease
Study type: Interventional

Summary: 
      The purpose of this study is to implement a pragmatic intervention in four (4) family
      medicine groups(FMGs) in the region of Saguenay-Lac-Saint-Jean (Quebec, Canada)for patients
      with chronic diseases.
    

Detailed description: 
      Chronic diseases represent a major health burden worldwide. Some people with chronic diseases
      require a higher level of care due to personal characteristics that increase their
      vulnerability. For these patients, nurse effective case management in primary care are
      associated with positive outcomes. Moreover, self-management programs, such as the standford
      program developed by the School of Medicine at the University of Standford in California
      (USA), are also recognized for their benefits on patients with chronic diseases.

      The aim of our project is to implement, within four (4) FMGs of the region of
      Saguenay-Lac-Saint-Jean , a practical intervention involving case management by a nurse to
      promote interdisciplinary person-centered monitoring and self-management support for highly
      vulnerable individuals with chronic diseases (diabetes, cardiovascular diseases, respiratory
      diseases, musculoskeletal diseases and/or chronic pain).

      The objectives of our study : 1) To analyze the implementation of the intervention in the
      participating FMGs in order to determine how the various contexts have influenced the
      implementation and the observed effects; 2) To evaluate the proximal and intermediate effects
      of the intervention on patients; 3) To conduct an economic analysis of the effectiveness and
      cost-benefit of the intervention.

      The analysis of the implementation will be conducted using realistic evaluation approaches
      and participatory practice within four categories of key players (FMG stakeholders,
      FMG/health center managers, patients and their families, health center partners or
      communities). The data will be obtained through individual or group interviews, literature
      reviews and documentation from the intervention undertaken. The evaluation of the effects in
      patients will be based on a pragmatic randomized experimental design before and after (six
      months) with delayed intervention in the control group. Economic analysis will include a
      cost-effectiveness analysis and a cost-benefit analysis.
    

Intervention name(s): Nurse case management and self-management support
Intervention type(s): Other
Intervention description(s): Case management: The intervention will focus on four main components: (1) A thorough evaluation of the patient's needs and resources; (2) Establishing and maintaining a patient-centered, individualized service plan (ISP); (3) Coordination of services among partners; and (4) Self-management support for patients and their families.
Self-management support: A standardized six-week program with interactive weekly group meetings led by two volunteer peer helpers (appointed trainers), who themselves have a chronic disease.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Supportive Care
Keywords: Primary care; Self-management; Self-support; Nurse case management