Connecting Low-Income Adults to Primary Care After Inpatient Discharge

Completed

• Conditions: Health Care Seeking Behavior; Health Care Utilization
• Interventions: Other: Access to primary care services

• Registration Number: NCT05567224
• Lead Sponsor: Vanderbilt University Medical Center

Brief Summary

Healthcare systems and insurers have tried to reduce costs by improving the care and coordination provided to patients with high healthcare spending. Often termed, "hotspotting", these interventions seek to lower costs by reducing care provided in fragmented, high-cost settings, including the emergency department and inpatient settings, by addressing the social determinants of health and improving patients' access to lower-cost, ambulatory settings. Vanderbilt University Medical Center (VUMC), in collaboration with Tennessee's Medicaid agency (TennCare), is piloting a program to reduce costs and improve the quality of care provided to high-risk TennCare enrollees by referring them from inpatient settings to VUMC primary care services. This study seeks to evaluate this pilot by comparing outcomes between Medicaid patients referred to VUMC primary care services and similar Medicaid patients not referred to VUMC primary care services using data from surveys and administrative sources, including electronic health records and health insurance claims.

Detailed Description

Not available

Study Timeline

• Study First Submitted: 2022-09-30
• Study First Submitted QC: 2022-09-30
• Study First Posted: 2022-10-05
• Study Start: 2022-12-15
• Status Verified: 2025-02
• Primary Completion: 2025-04-01
• Study Completion: 2025-04-01
• Last Update Submitted: 2025-04-28
• Last Update Posted: 2025-04-29

Recruitment & Eligibility

• Status: COMPLETED
• Sex: All
• Target Recruitment: 200

Inclusion Criteria

• Age 18 or older
• Currently enrolled in Tennessee's Medicaid Program (TennCare)
• Presenting in VUMC's inpatient setting
• Reporting no active relationship with a primary care doctor
• Lives in Davidson County, Tennessee, or a surrounding county

Exclusion Criteria

• Patients discharged to a setting other than the community (e.g. to a Skilled Nursing Facility)

Study & Design

• Study Type: OBSERVATIONAL
• Study Design: Not specified

Arm && Interventions

Group	Intervention	Description
Pilot Group	Access to primary care services	This group of TennCare recipients will be referred to VUMC primary care services and will be allowed to utilize these services for at least two years. Those referred to VUMC primary care services will be those who belong to the two of state's three Medicaid Managed Care plans who have agreed to participate in this pilot.

Primary Outcome Measures

Name	Time	Method
Number of Inpatient Admissions	30, 60, 90, 180, and 360 days	How many times the participant is hospitalized within the specified time period

Secondary Outcome Measures

Name	Time	Method
Number of Emergency Department Visits	30, 60, 90, 180, and 360 days	How many times the participant presents to the emergency department within the specified time period
Average of Disease Specific Outcomes	30, 60, 90, 180, and 360 days	Depending on the clinical information that is captured, disease specific clinical outcomes (e.g. prevalence of hypertension; HbA1C levels) will also be reported
Average Health Care Spending	30, 60, 90, 180, and 360 days	Health care expenditures by the patient within the specified time frame
Average Self-reported Health Status	30, 60, 90, 180, and 360 days	A measure of the patient's self-reported physical and mental health, as measured by a shorter, modified version of the Short Form (SF)-36
Number of Primary Care Visits	30, 60, 90, 180, and 360 days	How many times the participant has seen a primary care physician within the specified time period

Trial Locations

Locations (1)

Vanderbilt University Medical Center; 🇺🇸 Nashville, Tennessee, United States