Clinical trial NCT00238836: Anticipatory & Preventive Team Care (APTCare): At Risk Patients of Family Health Networks
Study type: INTERVENTIONAL
Overall status: UNKNOWN
Phase: PHASE2
PHASE3
Conditions: Diabetes
Chronic Obstructive Pulmonary Disease
Congestive Heart Failure
Hypertension
Lead sponsor: C. T. Lamont Primary Care Research Centre
Sponsor class: OTHER
Collaborators: name: Ontario Ministry of Health and Long Term Care
name: University of Ottawa
First posted: 2005-10-14
Enrollment: 240
Sex: ALL
Minimum age (years): 50
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: SINGLE_GROUP
Primary purpose: PREVENTION

Brief summary: The University of Ottawa and Élisabeth Bruyère Research Institute are conducting a study of preventive care for frail patients at risk of functional decline. At risk patients are assigned by chance to continue receiving their standard care from their family physician or receive additional care from a nurse practitioners and a pharmacist. In collaboration with the family physician, they develop an individualized care plan, a treatment and management road plan, for each patient, which they implement over the study period of one approximately year. The objective of the study is to compare the effectiveness of the model of care that includes the nurse practitioners and pharmacist against standard care in preventing functional decline, to determine the acceptability of this model of care to patients, their caregivers and the medical team, and to evaluate the cost implication of the program.


Eligibility criteria: Inclusion Criteria:

* 50 years and over
* 'At Risk' by having one or more of the following: a. Visits to emergency dept within the past 6 months; b. Admission to hospital for a medical problem in past 6 months; c. High service use profiles; d. Polypharmacy; e. Other high risk factors
* Capable of giving informed consent
* Able to use the Care Companion technology

Exclusion Criteria:

* Cognitive impairment such that they cannot give informed consent
* Unable or unwilling to use the telehomecare equipment
* Unlikely to tolerate the intensive intervention
* Language or cultural barriers
* Being acutely ill or having an unstable condition on entry to the study

Primary outcomes:
Secondary outcomes:
Other outcomes:
Locations:
city: Carp
country: Canada
facility: West Carleton Family Health Network
state: Ontario
Study officials:
affiliation: C. T. Lamont Primary Care Research Centre
name: William Hogg, MD
role: PRINCIPAL_INVESTIGATOR
affiliation: University of Ottawa
name: Jacques Lemelin, MD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Fletcher J, Hogg W, Farrell B, Woodend K, Dahrouge S, Lemelin J, Dalziel W. Effect of nurse practitioner and pharmacist counseling on inappropriate medication use in family practice. Can Fam Physician. 2012 Aug;58(8):862-8.
citation: Dahrouge S, Hogg W, Lemelin J, Liddy C, Legault F. Methods for a study of Anticipatory and Preventive multidisciplinary Team Care in a family practice. Can Fam Physician. 2010 Feb;56(2):e73-83.
citation: Gray D, Armstrong CD, Dahrouge S, Hogg W, Zhang W. Cost-effectiveness of Anticipatory and Preventive multidisciplinary Team Care for complex patients: evidence from a randomized controlled trial. Can Fam Physician. 2010 Jan;56(1):e20-9.
citation: Hogg W, Lemelin J, Dahrouge S, Liddy C, Armstrong CD, Legault F, Dalziel B, Zhang W. Randomized controlled trial of anticipatory and preventive multidisciplinary team care: for complex patients in a community-based primary care setting. Can Fam Physician. 2009 Dec;55(12):e76-85.