Improving How Older Adults at Risk for Cardiovascular Outcomes Are Selected for Care Coordination

Not Applicable

Completed

Conditions: Myocardial Infarction
Transient Ischemic Attack
Cardiovascular Diseases
Atrial Fibrillation
Heart Failure
Hyperlipidemias
Hypertension
Ischemic Heart Disease
Stroke
Diabetes Mellitus

Brief Summary: This pragmatic clinical trial embedded in an accountable care organization will determine the comparative effectiveness of two approaches for assigning care coordinators to older adults at risk for cardiovascular outcomes. The hypothesis is that assigning care coordinators to older adults based on perceived need will be more effective at preventing emergency department visits and hospitalizations compared to usual care.

Detailed Description: This project will use a pragmatic clinical trial embedded in an accountable care organization (ACO) to determine the comparative effectiveness of two different approaches for selecting older adults at risk for cardiovascular outcomes to receive support from care coordinators: (1) an approach that assigns older adults to care coordinators based on self-reported difficulty with care coordination, or (2) usual care, which generally assigns older adults to care coordinators after hospital discharge, regardless of perceived need. The investigators will include community-dwelling Medicare beneficiaries ≥65 years old with cardiovascular disease (CVD) or 1 or more CVD risk factors who have been attributed to the NewYork Quality Care ACO and who have fragmented care. The investigators will randomize the participants into two groups. This study is highly pragmatic, and the intervention is sustainable and scalable. Moreover, the proposed approach has the potential to improve care delivery and outcomes for older adults at risk for cardiovascular outcomes.

Recruitment & Eligibility

Inclusion Criteria

Medicare beneficiaries 65 years and older,
Attributed to the NewYork Quality Care accountable care organization,
Are community-dwelling,
Have cardiovascular disease or 1 or more cardiovascular risk factors, and
Had highly fragmented ambulatory care in the prior year (defined as a reversed Bice-Boxerman Index greater than or equal to 0.85)

Exclusion Criteria

Those who reside in long-term care or nursing home facilities (based on addresses in Medicare claims)
Enrolled in home hospice
Dementia (as measured in claims using the Bynum Standard 1-year definition)

Primary Outcome Measures

Name	Time	Method
Number of Emergency Department Visits or Hospital Admissions	Over 12 months (beginning 1 month after the start of care coordination)	Occurrence of an emergency department visit or hospital admission, as measured in Medicare claims. This outcome measure allows more than one event per participant.

Secondary Outcome Measures

Name	Time	Method
Acceptability	Up to 1 year of follow-up	Number of people in each group who accept care management
Appropriateness	Up to 1 year of follow-up	Number of participants who requested care management services that were in scope for the care managers' credentials
Fidelity	Up to 1 year of follow-up	Number of participants who received care management services, among those who requested care management services.
Efficiency	Up to 1 year of follow-up	The total number of care management encounters per group. This measure allows more than one encounter per participant.

Locations (1): New York Presbyterian Hospital - Weill Cornell Medicine
🇺🇸
New York, New York, United States
New York Presbyterian Hospital - Weill Cornell Medicine
🇺🇸New York, New York, United States