Intensive Management of At-risk Patients: a Randomized Controlled Trial
试验速览
- 阶段
- 不适用
- 发起方
- 入组人数
- 600
- 主要终点
- inpatient bed days
研究概览
简要总结
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.
详细描述
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.
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Parallel
- 主要目的
- Treatment
- 盲法
- Single (Participant)
盲法说明
Participants will not be informed that their care is different than usual care.
入排标准
- 性别
- All
- 接受健康志愿者
- 是
入选标准
- •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)
排除标准
- •enrolled in hospice
- •enrolled in Institutional Special Needs Plan
- •primary patient of study investigator
结局指标
主要结局
inpatient bed days
时间窗: 6 months
number of total participants' days of care in an inpatient setting
inpatient admissions
时间窗: 6 months
total number of participants' inpatient admissions
次要结局
- cost(6 months)
- average percent of participants contacted monthly(1 month)
- inpatient plus SNF bed days(6 months)
- average change in percent of high-priority HEDIS gaps(6 months)
- ED visits(6 months)
- 30-day readmissions(30 days)
- 180-day readmissions(180 days)
- ACSC admits(6 months)
- delta MLR(6 months)
- average change in staff satisfaction score(6 months)
- average percent post-acute contact within 1 week(1 week)
- average percent of high-priority tasks completed within 1 week(1 week)
- average percent of Gold patients contacted weekly(1 week)
- average change in participant satisfaction score(6 months)
研究者
Paul Bixenstine
Primary Care Physician
CareMore Health, San Bernardino