Use of Information Technology to Support Integration of Social Determinant of Health Services to Reduce Avoidable Emergency Department Visits
Trial Snapshot
- Phase
- Not Applicable
- Sponsor
- Enrollment
- 400
- Locations
- 2
- Primary Endpoint
- Change in Adoption and Use of IT Platform
Study Overview
Brief Summary
Working through regional Accountable Care Organizations (ACO) the sponsor will establish a 2-year pilot project to demonstrate that early recognition and intervention in the various Social Determinant of Health (SDoH) domains can reduce avoidable Emergency Department (ED) visits by high utilizers. The regional ACO's will contract with Medicaid Managed Care Plans to assign traditional high ED utilizing members to the pilot project. Members will be offered enhanced peer facilitated care management services connecting members with available SDoH community based services. Members fitting our eligibility criteria will self-select by way of completing a pilot project consent form.
Detailed Description
The project employs a two level intervention to include Peer Support Specialist (PSS) and Community Health Advocate (CHA). Contact and engagement with participating members will be through both direct intervention in the emergency department by Peer Support Specialist (the peer) as well as in the community for prevention visits and follow up by both the peer and Community Health Advocate. These well-positioned Peers and Community Health Advocates will address Behavioral and Social Determinants of Health (SDoH) concerns through a highly coordinated intervention supported by a common IT Medicaid member tracking platform. This research project will determine the feasibility of deploying a single shared IT platform that will include referral, appointment completion, and intervention outcome data. Project staff will develop a trusting relationship with the members and will improve member access and engagement with community-based services. The project will also seek to determine the impact on total cost of care through redirecting study participants to community resources that are more appropriate, and less expensive than return visits to the emergency department.
Study Design
- Study Type
- Interventional
- Allocation
- Na
- Intervention Model
- Single Group
- Primary Purpose
- Supportive Care
- Masking
- None
Eligibility Criteria
- Ages
- 18 Years to 65 Years (Adult, Older Adult)
- Sex
- All
- Accepts Healthy Volunteers
- No
Inclusion Criteria
- •Adults age 18 to 65
- •New York State Medicaid Managed Care Members
- •Have utilized emergency department services 6 or more times in a 12-month period
- •Have been assigned to the Pilot Project by their Medicaid Managed Care Plan
Exclusion Criteria
- •Individuals not assigned by a Managed Care Organization meeting the above criteria
Arms & Interventions
Medicaid Emergency Department High Utilizers
This Arm will include the following individuals
- Up to 400 Adults age 18 to 65
- New York State Medicaid Managed Care Members
- Have utilized emergency department services 6 or more times in a 12-month period
- Have been assigned to the Pilot Project by their Medicaid Managed Care Plan
Intervention: Peer Integrated Care Services (Behavioral)
Outcomes
Primary Outcomes
Change in Adoption and Use of IT Platform
Time Frame: Months 6, 12, 18, 24
Change in Number of Participating Agencies That Contribute Data to the IT System
Change in Total Cost of Care for Participating Members
Time Frame: Month 0, Month 24
Change in cost trend for participating members. Pre-study vs. study period.
Change in Engagement of Medicaid Member Participants with Peer Integration Care Services
Time Frame: Months 0, 3, 6, 9, 12, 15, 18, 21, 24
The change in acceptance by Medicaid Members of Peer Integrated Care Services
Secondary Outcomes
- Change in Emergency Room Visits by Participating Members(Month 0, 6, 12,18,24)