Evaluation of a Personalized Care Management Program for High Hospital Utilizers

Comorbidities and Coexisting Conditions Clinical Trial

Official title:

Effect of a Personalized Care Management Program on Hospital Inpatient Stays Among High Utilizers: A Randomized Clinical Trial

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT04727567
• Other study ID #: IRB00082498
• Secondary ID: 04-20-10E
• Status: Completed
• Start date: April 23, 2020
• Est. completion date: August 31, 2021

Study information

• Verified date: September 2021
• Source: Wake Forest University Health Sciences
• Contact: n/a
• Is FDA regulated: No
• Study type: Observational

Clinical Trial 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.

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.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 454
• Est. completion date: August 31, 2021
• Est. primary completion date: May 1, 2021
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years and older

Eligibility

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

Related Conditions & MeSH terms

• Comorbidities and Coexisting Conditions

Locations

Country	Name	City	State
United States	Atrium Health - Care Management Program	Charlotte	North Carolina

Sponsors (1)

Lead Sponsor	Collaborator
Wake Forest University Health Sciences

Country where clinical trial is conducted

United States, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Number of inpatient (IP) hospital encounters over a 12 month period	Inpatient encounter is defined as an admission to an Atrium Health acute care hospital	12 months
Secondary	Number of inpatient hospital encounters over a 6 month period	Inpatient encounter is defined as an admission to an Atrium Health acute care hospital	6 months
Secondary	Combined Inpatient and Observational hospital encounters - Atrium only	Combined number of IP and OBS encounters at Atrium Health hospitals	6 months
Secondary	Combined Inpatient and Observational hospital encounters - non-Atrium included	Combined number of IP and OBS encounters at Atrium Health and non-Atrium Health hospitals	6 months
Secondary	Combined Inpatient and Observational hospital encounters - Atrium only	Combined number of IP and OBS encounters at Atrium Health hospitals	12 month
Secondary	Combined Inpatient and Observational hospital encounters - non-Atrium included	Combined number of IP and OBS encounters at Atrium Health and non-Atrium Health hospitals	12 month
Secondary	Inpatient Readmission	Among patients with at least 1 encounter during the study period, 30-day all cause non-elective inpatient readmission rate to any AH hospital	6 month
Secondary	Inpatient Readmission	Among patients with at least 1 encounter during the study period, 30-day all cause non-elective inpatient readmission rate to any AH hospital	12 month
Secondary	Inpatient Readmission - Same Hospital	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	6 month
Secondary	Inpatient Readmission - Same Hospital	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	12 month
Secondary	Emergency Department Encounters	Number of patient emergency department encounters	6 month
Secondary	Emergency Department Encounters	Number of patient emergency department encounters	12 month
Secondary	Mortality	Dichotomous indicator of all-cause mortality within 6 months from the beginning of the study period	6 month
Secondary	Mortality	Dichotomous indicator of all-cause mortality within 12 months from the beginning of the study period	12 month
Secondary	Hospital Bed Days (Inpatient)	Total length of stay (LOS) in days (discharge date to admissions date) for acute care IP utilization	6 month
Secondary	Hospital Bed Days (Inpatient)	Total length of stay (LOS) in days (discharge date to admissions date) for acute care IP utilization	12 month
Secondary	Hospital Charges	Total accrued hospital billed charges for inpatient encounter at Atrium Health primary enterprise acute care facilities.	6 month
Secondary	Hospital Charges	Total accrued hospital billed charges for inpatient encounter at Atrium Health primary enterprise acute care facilities.	12 month