Health Information Technology Clinical Trial
Official title:
Transforming Outcomes for Patients Through Medical Home Evaluation & reDesign
The purpose of this study is to support enhancement, implementation, and evaluation of an
improved model for delivering improved primary care to high-risk older adults through the
use of health IT tools, focusing on issues related to the patient-centered primary care home
(PCPCH) and other similar high-value elements that are proposed to improve patient outcomes.
During this study, participating clinics will utilize the already-implemented Integrated
Care Coordination Information System (ICCIS). Clinic staff will meet with a practice
facilitator (monthly and as needed), and will track study activities and submit invoices via
ICCIS reporting. These invoices will be used to simulate a shared savings model where
clinics will be reimbursed based on their progress and effort towards their goals.
Clinics will set and work towards goals that they have chosen. Goals for the control arm are
self-selected by the clinics themselves; goals for the invention arm are related to
high-value elements (HVE) that have been identified as areas that can improve patient
outcomes. These HVE are:
1. Evidence-based Care Management Based on Need
2. Identification of At-Risk Populations
3. Patient Engagement and Alerts Based on Goals
4. Integrated Information for Care Management, especially around Utilization
5. Population Management Tools
n/a
Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Single Blind (Subject), Primary Purpose: Supportive Care
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