PACE-It: Primary Care Based Integrated Community Care Team Intervention
Study Details
Study Description
Brief Summary
PACE-It study is a non-blinded, mix-method randomized controlled trial within a single site. This study aims to test the feasibility of implementing a complex intervention comprising of
- a Primary Care Based integrated community care team delivery of person centered care, b) supported by a care co-ordination platform using a mobile application and its effectiveness in improving the glycemic control of patients living with Diabetes and have complex needs.
| Condition or Disease | Intervention/Treatment | Phase |
|---|---|---|
|
N/A |
Detailed Description
PACE-It study aims to test the feasibility of implementing a complex intervention comprising of a) a Primary Care Based Community Care Team delivery of person centered care b) supported by a care co-ordination platform using a mobile application and its effectiveness in improving the glycemic control of patients living with Diabetes and complex needs.
This is a non-blinded, mix-method randomised controlled trial within the Marine Parade Community. The primary outcome will be glycemic control measure by the Glycated Haemoglobin (HbA1c). Secondary outcomes include blood pressure, LDL-cholesterol, Patient Activation Measure, Medication Adherence and Quality of Life. Data on patient and provider satisfaction and implementation process will be collected by the Qualitative method.
Study Design
Arms and Interventions
| Arm | Intervention/Treatment |
|---|---|
| Experimental: Intervention arm Providers use PACE-It mobile application as a care co-ordination platform |
Other: PACE-It mobile application
Care co-ordination platform
|
| No Intervention: Usual care Providers use usual modes of communication (e.g., phone calls, emails) |
Outcome Measures
Primary Outcome Measures
- HbA1c [1 year]
Glycemic control
Secondary Outcome Measures
- Blood pressure [1 year]
Systolic and diastolic blood pressure (mmHg)
- LDL-cholesterol [1 year]
Low-density lipoprotein cholesterol
- Patient activation measure (PAM) [1 year]
Patient's activation levels
- Medication adherence measure (MARS-5) [1 year]
Patient's adherence to medication
- EQ-5D-5L [1 year]
Quality of life
- Patient satisfaction [1 year]
Qualitative survey and interview
- Provider's satisfaction [2 years]
Qualitative survey and interview
- Cost-effectiveness [2 years]
Cost-effectiveness of care model
- Implementation of care model [2 years]
Factors affecting implementation of care model
Eligibility Criteria
Criteria
Inclusion Criteria:
-
Living within the designated geographical zone
-
50 years and above
-
Satisfy the Medical Criteria below:
-
Diabetes with HbA1c ≥ 9% (within past 6 months), and
-
At least 1 complication
-
chronic kidney impairment stage 3 and above, or diabetes overt nephropathy,
-
ischaemic heart disease, or congestive cardiac failure,
-
peripheral arterial disease, or diabetes foot/ diabetes foot-related complications,
-
diabetic retinopathy/ treatment for retinopathy, and
-
stroke, or transient ischaemic attack
- Satisfy at least 2 conditions in the psycho-social, functional or activation domain of which 1 criteria must be from the psycho-social domain:
- Psycho-social issues
- Lack of care giver support i. No care-giver (when indicated) ii. Care-giver skills gap/ stress iii. Inability of copy when patient is the care-giver b. Difficult relationships (family/ workplace/ social network) c. Social isolation/ lack of social connectivity i. Lives alone ii. Lack of social network support d. Financial i. Financial difficulty/ insecurity ii. Housing/ shelter issues iii. Poor money management
-
Functional
-
Clinical Frailty Score ≥ 4, requiring help in instrumental activities of daily living (iADL)
-
Requires assistance in ADL or iADL
-
Activation a. Lack of ability to manage health - disengaged or overwhelmed i. Anxiety or disease-related distress ii. Confusion or lack of understanding of care plans iii. Non-adherence to medications/ follow up
-
Patient gives consent to participate
-
For patients who may be seeing a Primary Care Physician (PCP) outside of the polyclinic for chronic disease management and where the PCP has indicated consent to co-manage the patient with the PACE-It team including the polyclinic physician
-
Patient must be willing to receive care in the polyclinic
Exclusion Criteria:
-
Patients who are on follow up with Primary Care Physicians or General Practitioners elsewhere for management of their chronic conditions and they do not consent to co-managing patient with the PACE-It team
-
Patients who have severe cognitive impairment, depression or psychiatric conditions that interfere with the ability to engage with the healthcare team
-
Patients who are (i) not community ambulant or (ii) bed bound
-
Patients with terminal illness
-
Patients who have are in other programs or research studies
-
Patients who do not give consent
Contacts and Locations
Locations
| Site | City | State | Country | Postal Code | |
|---|---|---|---|---|---|
| 1 | SingHealth Polyclinics - Marine Parade, 80 Marine Parade Central, #01-792 | Singapore | Singapore | 440080 |
Sponsors and Collaborators
- SingHealth Polyclinics
- Ministry of Health, Singapore
- Agency for Integrated Care, Singapore
- SingHealth Regional Health System
Investigators
- Principal Investigator: Sinead Zhen Wang, Dr, SingHealth Polyclinics
Study Documents (Full-Text)
None provided.More Information
Publications
None provided.- 2020/2202