Preventing Tipping Points in High Comorbidity Patients: A Lifeline From Health Coaches

Launched by CLINICAL DIRECTORS NETWORK · Nov 22, 2019

Keywords

ClinConnect Summary

This clinical trial is studying ways to help patients with multiple chronic illnesses avoid serious health crises that could lead to hospital stays or increased disability. Researchers are comparing two different approaches: one that offers standard care through a Patient-Centered Medical Home (PCMH), and another that adds health coaching to help motivate patients in managing their health by setting personal goals. The trial involves adult patients from health centers in New York City and Chicago, specifically those who are already receiving care and have a high level of health challenges.

To participate, patients need to be established at one of the participating health centers and have a significant number of health problems, as indicated by a specific scoring system called the Charlson Comorbidity Index. Those with certain serious conditions, like advanced cancer or severe mental illness, are not eligible. Participants can expect to receive support and resources aimed at improving their health management while contributing to valuable research that could help many others in similar situations. This study is important because it aims to develop effective strategies that can be used widely in health centers serving low-income and minority patients across the country.

Gender

ALL

Eligibility criteria

• Inclusion Criteria:
• • Established patients of the participating Federally Qualified Health Centers (FHQCs)
• • Charlson comorbidity index ≥4
• Exclusion Criteria:
• • Metastatic cancer,
• • End stage renal disease on dialysis
• • Post-transplant
• • Severe mental illness
• • Drug/alcohol abuse
• • Cannot communicate in English or Spanish.