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Pursuing the Triple Aim in Hotspotters: Identification and Integrated Care
Sponsor: Leiden University Medical Center
Summary
Hotspotters are patients with complex care needs, defined by problems in multiple life domains and high acute care use. These patients often receive mismatched care, resulting in overuse of care and increased healthcare costs. Reliable data on (cost-)effective interventions for these patients are scarce. The goal of this study is to assess the cost-effectiveness of pro-active and integrated care. This approach includes: an intake consultation with Positive Health; multidisciplinary meetings with physician, mental healthcare nurse, social worker and the patient; a personalised care plan and proactive care management. We aim to include 200 patients, divided over 20 primary care practices.
Official title: The Hotspotters Project. Pursuing the Triple Aim in Hotspotters: Identification and Integrated Care
Key Details
Gender
All
Age Range
18 Years - Any
Study Type
INTERVENTIONAL
Enrollment
41
Start Date
2023-08-02
Completion Date
2026-12-31
Last Updated
2026-02-24
Healthy Volunteers
No
Interventions
Proactive, integrated and personalised care
During the intervention patients receive proactive, integrated and personalised care. An intake consultation using Positive Health tool, or a similar method, the needs of each patient is assessed. In a multidisciplinary meeting with the GP, mental health care practice nurse, a social worker and the patient, a personalised care plan is made. The personal is executed and a care coordinator maintains proactive contact with the patient. Clinical follow-up will be done via a second multidisciplinary meeting.
Locations (1)
Leiden University Medical centre, department of Public Healht and Primary care (PHEG), location Health Campus The Hague
Leiden, Netherlands