Intensive Management of At-risk Patients

Status Not yet recruiting

Clinical Trial 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.

Clinical Trial 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. ;

Study Design

Related Conditions & MeSH terms

Chronic Disease

Clinical Trial Details

NCT number	NCT04456725
Study type	Interventional
Source	CareMore Health, San Bernardino
Contact	Paul J Bixenstine, MD
Phone	909-296-8800
Email	paul.bixenstine@caremore.com
Status	Not yet recruiting
Phase	N/A
Start date	July 1, 2020
Completion date	December 31, 2020

View Details

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