Model for the Integral Assessment of Chronic Disease Management Supported in Information Technology and Communication.

A Randomized Clinical Trial to Investigate the Management for the Integral Assessment Model of Chronic Disease Supported in Information Technology and Communication.

Controlled and Randomized Clinical trial with 3 parallel groups (intervention group with a health platform NOMHADchronic, phone-based care group, usual care group) developed in the Valencia La Fe Health Department. 495 high-complexity chronic patients will be included according to a combined recruitment based on a risk predictive model plus clinical opinion. Patients will be followed-up during 12 months in order to evaluate health-related quality of life, mortality, health consumption, health direct cost and treatment satisfaction.

Inclusion Criteria:

• Age ≥18 years old.
• High complexity: according to a combined criteria a) predictive model of Valencia La Fe Health department for hospital resources consumption in next 12 months (probability >95%) and b) risk confirmation by a clinical team with experience on chronic patients management.
• Participants that accept to participate in the study by the informed consent signature
• Participants that don't meet any of the exclusion criteria

Exclusion Criteria:

• Age <18 años.
• Participants with cognitive or sensorial difficulties or with insufficient knowledge of one of the 2 official languages of Valencian Community that, according to the healthcare professional, may affect their study participation.
• No residents or temporary residents in the Health Department
• Homeless or participants with high-risk of social exclusion.
• Terminal patients or in palliative care according to the SECPAL (Spanish Society of Palliative Care) criteria .
• Community-dwelling patients
• Inability for mobile phone management if there is a caregiver with this capability.
• Participants without a phone line
• Non high-complexity chronic patients according to the recruitment healthcare professional.
• Members of the research team, workers related to the centers implied in the study or any other person directly involved in the study -
• First degree consanguinity or similar affinity with the team members.
• Participants already involved in case management.
• Participants already participating in clinical trials or experimental trials.
• Participants that don't accept to participate in the study or not signing the informed consent
• Participants with a main diagnostic of mental diseases
• Participants with active oncological diagnosis
• Participants already following specific interventions for hemodialysis, organ transplanting, day hospital
• Participants with an infectious chronic disease as unique chronic disease (HIV, BHV (Hepatitis B Virus)…)