Intensive Management of At-risk Patients
- Conditions
- Chronic Disease
- Registration Number
- NCT04456725
- Lead Sponsor
- CareMore Health, San Bernardino
- Brief Summary
The purpose of this study is to assess if intensive management of at-risk participants, utilizing longitudinal patient tracking, proactive outreach, multidisciplinary action planning and careful outcomes monitoring, will lead to better patient outcomes than usual care.
- Detailed Description
At-risk participants will be randomized 1:1 to either usual care or intensive management utilizing longitudinal patient tracking, proactive outreach, multidisciplinary action planning and careful outcomes monitoring for 6 months. Participants in the intervention group will be assigned to a partnership of one nurse practitioner and one medical assistant who will manage them with the support of the study team. Staff will focus on contacting all patients within one week of any emergency department visit or hospital discharge, contacting all highest-risk participants weekly and all participants monthly, and completing high-priority tasks for participant care within one week. The primary outcomes of this quality improvement study are inpatient bed days and number of inpatient admissions.
Recruitment & Eligibility
- Status
- UNKNOWN
- Sex
- All
- Target Recruitment
- 600
At-risk patients, meaning Gold, Silver, or Bronze tier, as identified by our member 360 platform:
- Gold tier - 6+ emergency department (ED) visits last year, annual spend >$100,000, 8 or more hierarchical condition category (HCC) diagnoses, readmission <30 days prior, or ambulatory care-sensitive condition (ACSC) hospitalization <30 days prior
- Silver tier - 4+ ED visits last year, annual spend >$75,000, 6 or more HCC diagnoses, readmission <90 days prior, substance abuse HCC diagnosis, behavioral health admit <90 days, 15+ chronic medications prescribed in the last 90 days (and not qualifying for Gold tier)
- Bronze tier - 3+ ED visits last year, annual spend >$50,000, 5 or more HCC diagnoses, 3+ hospitalizations last year, end-stage liver disease, end-stage renal disease, Medicare and Medicaid dual-enrolled, disease-management program patients with ACSC admission or ED visit in the last year, 10+ chronic medications in the last 90 days, 6+ health risk-assessment score, 12+ Edmonton Frail Scale score (and not qualifying for Gold or Silver tiers)
- enrolled in hospice
- enrolled in Institutional Special Needs Plan
- primary patient of study investigator
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Primary Outcome Measures
Name Time Method inpatient bed days 6 months number of total participants' days of care in an inpatient setting
inpatient admissions 6 months total number of participants' inpatient admissions
- Secondary Outcome Measures
Name Time Method average percent of participants contacted monthly 1 month average percent of participants contacted every 4 weeks
inpatient plus SNF bed days 6 months number of total days of participants' care in an inpatient or skilled nursing facility setting
average change in percent of high-priority HEDIS gaps 6 months average change in percent of open Healthcare Effectiveness Data and Information Set (HEDIS) measures that are high-priority, meaning statin use in diabetics and cardiovascular disease; medication adherence for oral diabetes, hypertension and statin; diabetes A1c control; and blood pressure control
ED visits 6 months participants' total emergency department visits
30-day readmissions 30 days participants' total inpatient readmissions within 30 days
180-day readmissions 180 days participants' total inpatient readmissions within 180 days
ACSC admits 6 months participants' inpatient admissions for ambulatory care sensitive conditions
delta MLR 6 months average change in each participant's medical loss ratio
average change in staff satisfaction score 6 months average difference in sum of Likert scale responses to staff satisfaction survey
average percent post-acute contact within 1 week 1 week average percent of participants contacted within 1 week of emergency department visit, hospital or skilled-nursing facility discharge
average percent of high-priority tasks completed within 1 week 1 week average percent of participant care tasks designated as high-priority that are completed within 1 week of being assigned
average percent of Gold patients contacted weekly 1 week average percent of participants in Gold tier contacted every week
average change in participant satisfaction score 6 months average difference in sum of Likert scale responses to participant satisfaction survey
cost 6 months participants' total medical expenditures