Cardiovascular Disease, Chronic Obstructive Pulmonary Disease, Diabetes, Heart Failure, Osteoporosis
Conditions
Brief summary
The investigators are studying the impact of the interventions of a multidisciplinary team (MDT) - consisting of a Coventry case manager, social worker, and medical director, alongside a Medco specialist pharmacist - on the hospitalization rates of high risk seniors with chronic conditions, compared with a usual care approach. The study will also examine the impact on quality of life, medication adherence, medical costs, hospital readmission rates, and a variety of other important measures. The outcome of COSS may support a means to further enhance and develop a comprehensive care model program by leveraging the partnership between a health plan and a pharmacy benefit manager.
Detailed description
The multidisciplinary team will provide face-to-face visits in a home setting with interventions that focus on five key areas: care transitions, self-management, care coordination, pharmacy and prevention, all designed to support high-risk Medicare members and their relationship with their primary care providers. If the study proves to reduce hospitalizations in the senior population, it could provide important guidance for future efforts to reduce the cost and improve the quality of care for seniors with chronic conditions.
Interventions
OTHERMultidisciplinary team interventions
The multidisciplinary team will determine which intervention should be applied to the participant in the intervention group based on their health risk assessment responses as well as medication review and visual inspection of the home.
OTHERMultidisciplinary team bimonthly visits either in person or via telephone.
OTHERUsual case management and pharmacy management as provided by the health Plan and the pharmacy benefit manager
Sponsors
Coventry Health Care, Inc.
Medco Health Solutions, Inc.
Eligibility
Sex/Gender
ALL
Age
65 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Inouye Risk Score \>3 calculated on Coventry Claims * Medicare Advantage beneficiaries age \> 65 years * Continuous eligibility \> 12 months prior to study * Ability to be contacted via telephone * Subject is willing and able to provide informed consent * Willing to comply with all study procedures and be available for the duration of the study
Exclusion criteria
* Active cancer treatment (i.e. chemotherapy or radiation) in the past 6 months * Living anywhere other than a community setting \[i.e. Skilled nursing facility (SNF)\] * Just-In-Time (JIT) Members * Members with a geographic location \> 60 from either St. Louis or Kansas City, MO. * Solid organ transplant recipients * Active enrollment in another clinical research study
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Determine the impact of multidisciplinary team interventions in reducing the rate of non-elective hospitalizations over a 12 month period compared to usual care | 12 months |
Secondary
| Measure | Time frame |
|---|---|
| Determine the impact of multidisciplinary team interventions versus usual care on health-related quality of life (HR-QOL) | 12 months |
| Determine the impact of MDT interventions versus usual care on inpatient costs associated with non-elective hospital events [rehabilitation, physician, incurred but not reported (IBNR)] | 12 months |
| Determine the impact of multidisciplinary team interventions versus usual care on total outpatient costs (physician, pharmacy,rehabilitation) | 12 months |
| Determine the impact of multidisciplinary team interventions on the rate of emergency room visits not resulting in hospitalization in a 24 hour period or less. | 12 months |
| Determine the impact of multidisciplinary team interventions versus usual care on rate of non-elective hospitalizations by chronic condition | 12 months |
| Determine the impact of multidisciplinary team interventions versus usual care on non-elective hospital readmissions at 30, 60, and 90 days following the first non-elective hospitalization event | 12 |
| Determine the impact of multidisciplinary team interventions versus usual care on the length of stay (LOS) of each non-elective hospitalization | 12 months |
| Determine the impact of multidisciplinary team interventions versus usual care on satisfaction with care | 12 months |
Countries
United States
Outcome results
None listed