Chronic Diseases in Primary Care

Sponsor
Universita di Verona
Study ID
NCT07479810
Status
Enrolling By Invitation

Conditions

  • Chronic Disease

Eligibility Criteria

Sex
ALL
Age
65 Years - N/A
Healthy Volunteers
Not accepted

Interventions

  • Proactive Intervention — OTHER
    The educational program will be carried out as a structured intervention, aiming to actively involve patients in their own healthcare pathway, promoting changes in behavior and self-care. The first act will consist of a double-level assessment, first having nurses collect data to assess the educational needs, then delving into a structured assessment of social and educational needs from lifestyle, self-care, medication adherence, and frailty risk. After that, four communication approaches will be implemented to enhance educational effectiveness: teach-back, motivational interviewing, the SHERPA model, and Calgary Family Interviews.

Study Details

This quasi-experimental study aims to assess if a nurse-led proactive intervention can enhance self-care and reduce hospitalizations or accesses to emergency department visits in chronically ill adults over 65 years old. The questions that it seeks to answer are the following: 1. Can a structured, proactive nurse-led intervention reduce hospitalizations and access to emergency departments? 2. Can this intervention improve self-care, medication adherence, and the overall quality of life? To assess its effectiveness, researchers will evaluate health outcomes before and after carrying out the intervention. Participants will receive an initial assessment to identify specific educational needs. To enhance self-care and symptom management, patients will participate in at least three scheduled follow-up sessions (via phone call or face-to-face) during the following six months. They will also complete questionnaires assessing lifestyle quality, medication adherence, and self-care abilities.

Key Dates

First listed
Mar 18, 2026
Start date
Nov 1, 2024
Status verified
Mar 2026
Primary completion
Jan 31, 2025
Completion
Sep 30, 2026

Study Design

Enrollment
100 participants (estimated)
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
SUPPORTIVE_CARE

Arms

  • Other: Intervention
    Single arm

Primary Outcome Measure

Composite Outcome - access to the emergency department or hospitalization [ Time Frame: 6 and 12 months pre-post ]

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