Comorbidities and Coexisting Conditions
Conditions
Keywords
Patient Care Management, Patient Hospital Admissions
Brief summary
This randomized clinical trial intends to evaluate the effectiveness of enrollment in Atrium Health's Multiple Visit Patient (MVP) care management program compared to usual care on reducing 12-month total inpatient hospital utilization among patients with high past volume of hospital inpatient stays.
Detailed description
The list of patients with four or more inpatient hospital visits in 2019 will be pulled from the Atrium Health electronic data warehouse (EDW) by IAS Clinical Quality Analytics, and eligibility for the MVP program of patients on this list will be determined by the Population Health's Care Management team based on predefined eligibility criteria. IAS CORE will randomize eligible participants into one of two groups: 1) MVP program; or 2) usual care. Population Health's Multiple Visit Patient (MVP) care management program aims to manage health and lower hospital utilization among patients with a history of high inpatient hospital stays at Atrium Health. Patients eligible for the program have four or more inpatient visits over the 12-month period prior to enrollment. Once enrolled, each MVP program participant receives on-going support from an assigned MVP care manager and larger care management team, including the following core program components: 1. customized care plan developed for each patient at the time of enrollment 2. routine, virtual health monitoring and collaborative care management team-based review 3. personalized navigation and coordination across multidisciplinary Atrium Health services, as needed 4. education, health coaching, and support via telephonic and in-person interactions, as needed The control group will receive usual care. Upon completion of the 12-month period during which outcomes data will be accrued, the study will evaluate whether 12-month participation in the MVP program care management program, compared to usual care, reduced inpatient hospital use.
Interventions
None listed
Sponsors
Wake Forest University Health Sciences
Study design
Observational model
CASE_CONTROL
Time perspective
PROSPECTIVE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* 18 years of age or older * 4 or more inpatient hospital visits across Atrium Health Metro hospitals in 2019
Exclusion criteria
* Existing MVP participants * Patients who at the time of identification for the MVP program are: * Actively enrolled in a Levine Cancer Institute oncology navigation program * Actively receiving hospice or palliative care * Attributed to a primary care provider at an outside healthcare system * Patients whose primary residence is a skilled nursing facility
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Number of inpatient (IP) hospital encounters over a 12 month period | 12 months | Inpatient encounter is defined as an admission to an Atrium Health acute care hospital |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Combined Inpatient and Observational hospital encounters - Atrium only | 6 months | Combined number of IP and OBS encounters at Atrium Health hospitals |
| Combined Inpatient and Observational hospital encounters - non-Atrium included | 6 months | Combined number of IP and OBS encounters at Atrium Health and non-Atrium Health hospitals |
| Inpatient Readmission | 6 month | Among patients with at least 1 encounter during the study period, 30-day all cause non-elective inpatient readmission rate to any AH hospital |
| Inpatient Readmission - Same Hospital | 6 month | Among patients with at least 1 encounter during the study period, 30-day all cause non-elective inpatient readmission rate to the same AH hospital as the index encounter |
| Number of inpatient hospital encounters over a 6 month period | 6 months | Inpatient encounter is defined as an admission to an Atrium Health acute care hospital |
| Mortality | 6 month | Dichotomous indicator of all-cause mortality within 6 months from the beginning of the study period |
| Hospital Bed Days (Inpatient) | 6 month | Total length of stay (LOS) in days (discharge date to admissions date) for acute care IP utilization |
| Hospital Charges | 6 month | Total accrued hospital billed charges for inpatient encounter at Atrium Health primary enterprise acute care facilities. |
| Emergency Department Encounters | 6 month | Number of patient emergency department encounters |
Countries
United States
Outcome results
None listed