Fostering a Sustainable Community Care Team (CCT)

Overview

About this study

The purpose of this study is to create and evaluate a sustainable referral process from primary care to a Community Care Team (CCT) for patients with chronic conditions using an implementation science framework and qualitative methods. Ultimately, this referral process will be available to inform the CCT locally as well as state- and nation-wide.

Participation eligibility

Participant eligibility includes age, gender, type and stage of disease, and previous treatments or health concerns. Guidelines differ from study to study, and identify who can or cannot participate. There is no guarantee that every individual who qualifies and wants to participate in a trial will be enrolled. Contact the study team to discuss study eligibility and potential participation.

Inclusion Criteria:

Patients:
- Age 18 or older
- One or more chronic conditions
- No major barriers to consent (i.e. dementia, severe hearing or visual impairment).
Providers:
- Providing primary care services for patients with chronic conditions at Mayo Clinic
- Who are familiar with the CCT or could refer patients to it in the future
Social Workers:
- Providing social work services to patients with chronic conditions
- Who are familiar with the CCT or could refer patients to it in the future
Nurse Care Coordinators:
- Providing care coordination services to patients with chronic conditions
- Who are familiar with the CCT or could refer patients to it in the future
Public Health Nurses:
- Providing nursing services to the patient population of interest through Olmsted County Public Health
- Who are familiar with the CCT or could refer patients to it in the future

Exclusion Criteria:

There are no exclusion criteria for providers.
There are no exclusion criteria for social workers.
There are no exclusion criteria for nurse care coordinators.
There are no exclusion criteria for Public Health Nurses

Participating Mayo Clinic locations

Study statuses change often. Please contact the study team for the most up-to-date information regarding possible participation.

Mayo Clinic Location	Status
Rochester, Minn. Mayo Clinic principal investigator Kasey Boehmer, Ph.D., M.P.H.	Closed for enrollment

Mayo Clinic Location

Status

Rochester, Minn.

Mayo Clinic principal investigator

Kasey Boehmer, Ph.D., M.P.H.

Closed for enrollment

More information

Publications

Publications are currently not available

Clinical Trials