Evaluation of a Personalized Care Management Program for High Hospital Utilizers

Completed

• Conditions: Comorbidities and Coexisting Conditions

• Registration Number: NCT04727567
• Lead Sponsor: Wake Forest University Health Sciences

Brief Summary

This randomized clinical trial intends to evaluate the effectiveness of enrollment in Atrium Health's Multiple Visit Patient (MVP) care management program compared to usual care on reducing 12-month total inpatient hospital utilization among patients with high past volume of hospital inpatient stays.

Detailed Description

The list of patients with four or more inpatient hospital visits in 2019 will be pulled from the Atrium Health electronic data warehouse (EDW) by IAS Clinical Quality Analytics, and eligibility for the MVP program of patients on this list will be determined by the Population Health's Care Management team based on predefined eligibility criteria. IAS CORE will randomize eligible participants into one of two groups: 1) MVP program; or 2) usual care.

Population Health's Multiple Visit Patient (MVP) care management program aims to manage health and lower hospital utilization among patients with a history of high inpatient hospital stays at Atrium Health. Patients eligible for the program have four or more inpatient visits over the 12-month period prior to enrollment. Once enrolled, each MVP program participant receives on-going support from an assigned MVP care manager and larger care management team, including the following core program components:

1. customized care plan developed for each patient at the time of enrollment

2. routine, virtual health monitoring and collaborative care management team-based review

3. personalized navigation and coordination across multidisciplinary Atrium Health services, as needed

4. education, health coaching, and support via telephonic and in-person interactions, as needed

The control group will receive usual care.

Upon completion of the 12-month period during which outcomes data will be accrued, the study will evaluate whether 12-month participation in the MVP program care management program, compared to usual care, reduced inpatient hospital use.

Basic Information
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Recruitment & Eligibility
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Study & Design
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Trial Locations

Study Timeline

• Study Start: 2020-04-23
• Study First Submitted: 2021-01-12
• Study First Submitted QC: 2021-01-26
• Study First Posted: 2021-01-27
• Primary Completion: 2021-05-01
• Study Completion: 2021-08-31
• Status Verified: 2021-09
• Last Update Submitted: 2022-04-14
• Last Update Posted: 2022-04-22

Recruitment & Eligibility

• Status: COMPLETED
• Sex: All
• Target Recruitment: 454

Inclusion Criteria

• 18 years of age or older
• 4 or more inpatient hospital visits across Atrium Health Metro hospitals in 2019

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Exclusion Criteria

• Existing MVP participants
• Patients who at the time of identification for the MVP program are:
• Actively enrolled in a Levine Cancer Institute oncology navigation program
• Actively receiving hospice or palliative care
• Attributed to a primary care provider at an outside healthcare system
• Patients whose primary residence is a skilled nursing facility

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Study & Design

• Study Type: OBSERVATIONAL
• Study Design: Not specified

Primary Outcome Measures

Name	Time	Method
Number of inpatient (IP) hospital encounters over a 12 month period	12 months	Inpatient encounter is defined as an admission to an Atrium Health acute care hospital

Secondary Outcome Measures

Name	Time	Method
Mortality	12 month	Dichotomous indicator of all-cause mortality within 12 months from the beginning of the study period
Inpatient Readmission	12 month	Among patients with at least 1 encounter during the study period, 30-day all cause non-elective inpatient readmission rate to any AH hospital
Combined Inpatient and Observational hospital encounters - Atrium only	12 month	Combined number of IP and OBS encounters at Atrium Health hospitals
Inpatient Readmission - Same Hospital	12 month	Among patients with at least 1 encounter during the study period, 30-day all cause non-elective inpatient readmission rate to the same AH hospital as the index encounter
Emergency Department Encounters	12 month	Number of patient emergency department encounters
Combined Inpatient and Observational hospital encounters - non-Atrium included	12 month	Combined number of IP and OBS encounters at Atrium Health and non-Atrium Health hospitals
Hospital Bed Days (Inpatient)	12 month	Total length of stay (LOS) in days (discharge date to admissions date) for acute care IP utilization
Hospital Charges	12 month	Total accrued hospital billed charges for inpatient encounter at Atrium Health primary enterprise acute care facilities.
Number of inpatient hospital encounters over a 6 month period	6 months	Inpatient encounter is defined as an admission to an Atrium Health acute care hospital

Trial Locations

Locations (1)

Atrium Health - Care Management Program; 🇺🇸 Charlotte, North Carolina, United States