Ambulatory ICU Study for Medically and Socially Complex Patients
- Conditions
- Primary Health CareHealth ServicesComorbidity
- Interventions
- Other: SUMMIT interventionOther: Enhanced usual care
- Registration Number
- NCT03224858
- Lead Sponsor
- Oregon Health and Science University
- Brief Summary
This is a prospective randomized wait-list control study to determine whether a stand-alone, co-located team of physician, mental health behaviorist, and care coordinators with decreased panel size (aka "intensive primary care") will reduce inpatient and emergency care utilization, inpatient costs of care, and improve patient activation and experience for medically and socially complex patients, compared to enhanced usual care at 6 and 12 months. Participants with multiple co-morbidities, and meet utilization criteria will have the opportunity to enroll; half the participants will start the intervention immediately, while half will continue enhanced usual care for 6 months before beginning the intervention.
- Detailed Description
The goal of this study is to conduct an evaluation of an "Ambulatory-ICU" model of primary care for "high utilizer" patients with medical, behavioral, and social complexity. A small proportion of patients use \> 50 % of healthcare resources. It is currently unknown what interventions can help reduce inappropriate utilization due to lack of studies with rigorous study design, particularly in patients with high rates of homelessness, mental illness and substance use. The use of high-risk teams for select patients is a promising model of primary care that removes barriers to accessing usual care services by centralizing medical and behavioral clinical services, promotes ability to outreach beyond the clinic, and promote continuity of care and trust-building between patient and provider teams.
This study will test the hypothesis that a stand-alone clinic based intervention of a multidisciplinary, co-located physician, mental health behaviorist, nursing, pharmacist, and care coordinators with reduced panel size, and focus on patient capacity building and decreasing treatment burden will improve health outcomes at 6 and 12 months in a low-income high utilizer population with history of homelessness.
Enhanced usual care comprises of care delivered at Old Town Clinic (OTC) a Federally Qualified Health Center (FQHC) that is modeled on the Patient Centered Medical Home (PCMH) model. Patients have a designated primary care physician and care team with access to chronic disease education, mental health, social work, and substance abuse programs through referral system. In addition, participants thought to have difficulty engaging in primary care have access to a Health Resilience Specialist, a community health worker intervention who conducts outreach and assists the patient in care navigation.
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 200
• One or more of the following medical diagnoses:
- congestive heart failure
- uncontrolled diabetes
- end stage liver disease
- chronic kidney disease (stage III or higher)
- chronic obstructive pulmonary disease (group C or D)
- chronic or severe soft tissue infections or ulcers
- osteomyelitis
- failure to thrive
And/OR:
• One or more of the following behavioral health diagnoses:
- psychotic disorder
- mood disorder
- post-traumatic stress disorder
- active substance use disorder
And/OR
• One or more of the following utilization patterns:
- 1+ medical hospital admission in prior 6 months
- frequent missed appointments (cancel or no-show for >5 primary care or specialty appointments in previous 12 months
- Non-English speaking
- Patients on hospice, nursing home, rehabilitation, or other institutional or long term care facility
- Inability to consent (as demonstrated by teach back of the consent process)
- Diagnosis of metastatic brain cancer
- Inability to participate in follow up phone due to aphasia, severe hearing impairment, or lack of access to telephone
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description SUMMIT intervention group SUMMIT intervention This group will transfer primary care to the SUMMIT team, which consists of: 1 primary care provider, 1 clinical nurse, 1 team manager, 2 care-coordinators, 2 behavioralists, 1 clinical pharmacist. This interdisciplinary team will have reduced patient panel load and increased flexibility in time and scheduling in order to foster trust and continuity with the patient with a goal of decreasing treatment burden and increasing patient capacity. Specific activities that participants will receive include: 1) comprehensive initial intake and care plan development that incorporates patient goal setting; 2) flexible scheduling of appointments with outreach; 3) transitional care coordination; 4) built-in behavioural counselling and case management; 5) regular review of care plan by team members. enhanced usual care group Enhanced usual care This group will continue to receive primary care as usual for 6 months. This includes care provided by the patient's existing primary care provider, access to a clinic's Health Resilience outreach worker, mental health consultation, and other services provided by usual care. After 6 months, the baseline survey is administered and the participant will transfer care to the intervention as described above in the SUMMIT intervention group.
- Primary Outcome Measures
Name Time Method Emergency Care visits 6 months Administrative data will be used to determine Emergency Department (ED) visits over study period
Primary care utilization 6 months Clinic administrative data will be used to determine primary care visits over study period
Patient Activation Measure (PAM) 6 months Study survey of the PAM measure is a validated instrument to assess patient self-efficacy
Patient Experience (ambulatory CAHPS) 6 months Study survey of patient reported assessment of patient experience
Medical Hospitalizations 6 months Administrative data will be used to determine hospital admissions
- Secondary Outcome Measures
Name Time Method Life Chaos 6 months Study survey of a validated instrument to assess self-reported life chaos
Medical Hospitalizations 12 months Administrative data will be used to determine hospital admissions
Functional status using Short Form (SF)-12 survey 6 months patient reported survey of functional status
Emergency Care visits 12 months Administrative data will be used to determine ED visits
inpatient costs of care 6 months claims data for patients will be used to determine costs of inpatient care
inpatient average length of stay 6 months Administrative data will be used to determine average length of stay each hospitalization
Edmonton Symptom Assessment Scale (ESAS) palliative measure 6 months Study survey with one question from the ESAS questionaire
Patient Activation Measure (PAM) 12 months Study survey of the PAM measure is a validated instrument to assess patient self-efficacy
number of falls 6 months Study survey with question asking how many falls over the last 6 months
Primary care utilization 12 months Clinic administrative data will be used to determine primary care visits over study period
Trial Locations
- Locations (1)
Central City Concern
🇺🇸Portland, Oregon, United States