Chronic Disease
Conditions
Keywords
high need high cost, population health, care management, quality improvement, ambulatory care, primary care, readmission prevention
Brief summary
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.
Detailed description
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.
Interventions
BEHAVIORALIntensive management
The intervention group will be assigned to a partnership of one nurse practitioner and one medical assistant who will manage them intensively, with the support of the study team.
BEHAVIORALControl
Usual care
Sponsors
CareMore Health, San Bernardino
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
SINGLE (Subject)
Masking description
Participants will not be informed that their care is different than usual care.
Eligibility
Sex/Gender
ALL
Healthy volunteers
Yes
Inclusion criteria
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)
Exclusion criteria
* enrolled in hospice * enrolled in Institutional Special Needs Plan * primary patient of study investigator
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| inpatient bed days | 6 months | number of total participants' days of care in an inpatient setting |
| inpatient admissions | 6 months | total number of participants' inpatient admissions |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| inpatient plus SNF bed days | 6 months | number of total days of participants' care in an inpatient or skilled nursing facility setting |
| average percent of participants contacted monthly | 1 month | average percent of participants contacted every 4 weeks |
| average change in percent of high-priority HEDIS gaps | 6 months | average change in percent of open Healthcare Effectiveness Data and Information Set (HEDIS) measures that are high-priority, meaning statin use in diabetics and cardiovascular disease; medication adherence for oral diabetes, hypertension and statin; diabetes A1c control; and blood pressure control |
| average change in staff satisfaction score | 6 months | average difference in sum of Likert scale responses to staff satisfaction survey |
| average change in participant satisfaction score | 6 months | average difference in sum of Likert scale responses to participant satisfaction survey |
| average percent of high-priority tasks completed within 1 week | 1 week | average percent of participant care tasks designated as high-priority that are completed within 1 week of being assigned |
| average percent post-acute contact within 1 week | 1 week | average percent of participants contacted within 1 week of emergency department visit, hospital or skilled-nursing facility discharge |
| ED visits | 6 months | participants' total emergency department visits |
| 30-day readmissions | 30 days | participants' total inpatient readmissions within 30 days |
| 180-day readmissions | 180 days | participants' total inpatient readmissions within 180 days |
| ACSC admits | 6 months | participants' inpatient admissions for ambulatory care sensitive conditions |
| cost | 6 months | participants' total medical expenditures |
| delta MLR | 6 months | average change in each participant's medical loss ratio |
| average percent of Gold patients contacted weekly | 1 week | average percent of participants in Gold tier contacted every week |
Other
| Measure | Time frame | Description |
|---|---|---|
| number of in-person visits | 6 months | total number of in-person care visits by participants |
| average change in RAF | 6 months | average change in each participant's Risk Adjustment Factor |
| average number of high-priority tasks completed per week | 1 week | average number of participant care tasks designated high-priority completed per week |
| average time on high-priority tasks per week | 1 week | average amount of time in minutes per week spent by staff in attempting to complete high-priority participant care tasks |
Contacts
Primary ContactPaul J Bixenstine, MD
Outcome results
None listed