EMBOSS A Person-centred Integrated-care for Chronic Diseases in Patients of Low Socio Economic Status (EMBOSS)
Chronic Condition, Chronic Conditions, Multiple
About this trial
This is an interventional treatment trial for Chronic Condition focused on measuring Primary care, Person-centered, Integrated-care, Health literacy, Health disparities, Socio-economic status, General practice
Eligibility Criteria
Inclusion Criteria: Currently enrolled in any of the single disease management programmes (usual care) for DM2, COPD, asthma or CVD Exclusion Criteria: Limited life expectancy (less than 3 months) Patients with high level of SES (or educational level > MBO2)
Sites / Locations
- RadboudUMCRecruiting
Arms of the Study
Arm 1
Arm 2
Experimental
No Intervention
Person-centred integrated care intervention
Usual care
The core of the person-centered approach is a cyclical process and for EMBOSS developed for patients with low SES. The practice nurse in the GP will act as case manager and can consult other health providers. The first step in the intervention is assessing the integral health status of the patient (health across multiple domains), using a visual conversation tool. The second step is discussing the results with the patient. Personal goals are formulated in the third step. In the fourth step, the healthcare professional and patient will choose through shared-decision making the most appropriate interventions and support to achieve these goals, which are documented in a personal plan. Next, referrals are made if necessary and the treatment is started. An evaluation is planned and carried out. All practices in the EMBOSS intervention group will be trained by Pharos on how to recognize and provide GDM to low SES patients using appropriate communication skills and the specific tools.
Practices in the control group provide care as usual, which consists of the SDM programmes according to the national care standards and General Practice guidelines (NHG) for DM2, COPD and CVD. According to these protocolised programmes, patients with COPD, CVD or DM2 visit their general practice at a standard frequency per year (1 - 4 times) and standard monitoring measurements and topics are discussed. The practices that are randomised to the control group will not receive any additional training related to this study.