Connecting Low-Income Adults to Primary Care After Inpatient Discharge

Health Care Utilization Clinical Trial

Official title:

Connecting Low-Income Adults to Primary Care After Inpatient Discharge

Clinical Trial Details — Status: Active, not recruiting

Administrative data

• NCT number: NCT05567224
• Other study ID #: 221128
• Status: Active, not recruiting
• Start date: December 15, 2022
• Est. completion date: October 1, 2026

Study information

• Verified date: April 2024
• Source: Vanderbilt University Medical Center
• Contact: n/a
• Is FDA regulated: No
• Study type: Observational

Clinical Trial Summary

Healthcare systems and insurers have tried to reduce costs by improving the care and coordination provided to patients with high healthcare spending. Often termed, "hotspotting", these interventions seek to lower costs by reducing care provided in fragmented, high-cost settings, including the emergency department and inpatient settings, by addressing the social determinants of health and improving patients' access to lower-cost, ambulatory settings. Vanderbilt University Medical Center (VUMC), in collaboration with Tennessee's Medicaid agency (TennCare), is piloting a program to reduce costs and improve the quality of care provided to high-risk TennCare enrollees by referring them from inpatient settings to VUMC primary care services. This study seeks to evaluate this pilot by comparing outcomes between Medicaid patients referred to VUMC primary care services and similar Medicaid patients not referred to VUMC primary care services using data from surveys and administrative sources, including electronic health records and health insurance claims.

Recruitment information / eligibility

• Status: Active, not recruiting
• Enrollment: 200
• Est. completion date: October 1, 2026
• Est. primary completion date: December 1, 2024
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

• Age 18 or older

• Currently enrolled in Tennessee's Medicaid Program (TennCare)

• Presenting in VUMC's inpatient setting

• Reporting no active relationship with a primary care doctor

• Lives in Davidson County, Tennessee, or a surrounding county

Exclusion Criteria:

• Patients discharged to a setting other than the community (e.g. to a Skilled Nursing Facility)

Related Conditions & MeSH terms

• Health Care Seeking Behavior
• Health Care Utilization

Intervention

Other:
• Access to primary care services
Those in the pilot group will be referred to primary care services and allowed to utilize them for at least two years. Primary care services include access to a primary care physician, medical management, and other tasks typically performed by a general practitioner. Those referred to primary care services will not have access to other VUMC outpatient services.

Locations

Country	Name	City	State
United States	Vanderbilt University Medical Center	Nashville	Tennessee

Sponsors (1)

Lead Sponsor	Collaborator
Vanderbilt University Medical Center

Country where clinical trial is conducted

United States, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Number of Inpatient Admissions	How many times the participant is hospitalized within the specified time period	30, 60, 90, 180, and 360 days
Secondary	Number of Emergency Department Visits	How many times the participant presents to the emergency department within the specified time period	30, 60, 90, 180, and 360 days
Secondary	Number of Primary Care Visits	How many times the participant has seen a primary care physician within the specified time period	30, 60, 90, 180, and 360 days
Secondary	Average Health Care Spending	Health care expenditures by the patient within the specified time frame	30, 60, 90, 180, and 360 days
Secondary	Average Self-reported Health Status	A measure of the patient's self-reported physical and mental health, as measured by a shorter, modified version of the Short Form (SF)-36	30, 60, 90, 180, and 360 days
Secondary	Average of Disease Specific Outcomes	Depending on the clinical information that is captured, disease specific clinical outcomes (e.g. prevalence of hypertension; HbA1C levels) will also be reported	30, 60, 90, 180, and 360 days