Comprehensive Care Physician: Integrated Inpatient and Outpatient Care for Patients at High Risk of Hospitalization

NCT01929005 | Active Not Recruiting

• 2 other identifiers: IRB12-1440FP050658-01-PR
• Study Type: interventional
• Target: 2,008
• Locations: 1 country
• Sites: 1

Brief Summary

The investigators propose an innovative new model of care in which patients identified to be at high risk of hospitalization are offered care by a physician who will direct their care both in the hospital and in clinic but is able to do so because they see patients only at high risk of hospitalization. This allows these physicians to have a panel of patients that is small enough that they can provide them with continuing ambulatory care but sick enough for those physicians to have enough of their patients hospitalized at any time to justify having the physician spend several hours each morning seeing those patients in the hospital, making the model economically viable and clinically valuable for the patient. The investigators estimate that each of the 5 physicians the investigators propose to establish in this model will serve a panel of about 200 patients in steady state with an average of 10 days of expected hospitalization and $75,000 each in Medicare spending per year, totaling $75 million annually. The investigators estimate that a 1% reduction in costs for these patients will be more than enough to cover the ongoing costs of the model the investigators propose; this is because the investigators' program reorganizes care rather than adding new forms of care.

Conditions

Medicare Patients; High Risk of Hospitalizations

Keywords

Comprehensive care; Medicare; Cost-sharing; Quality of care

Outcome Measures

Primary Outcomes (2)

• Patient Satisfaction

  patient satisfaction measured by Consumer Assessment of Health Plans (CAHPs) instrument

  Every 3 months after patient enrollment up to 3 years

• Total Cost of Care

  Total cost of care will be measured using Medicare claims data obtained from RESDAC to examine all care that charged to Medicare, including use of acute care hospitals, physician services, SNF, home health, hospice, etc., and Part D. We will also seek to link to data from Illinois Medicaid for our dual eligibles.

  Cumulative costs after enrollment up to 3 years

Secondary Outcomes (4)

• Patient outcomes

  Every 3 months after enrollment up to 3 years

• Care utilization

  Cumulative utilization from patient enrollment up to 3 years

• Doctor-patient relationship

  Every 3 months after enrollment up to 3 years

• Mortality

  Cumulative after enrollment up to 3 years

Other Outcomes (1)

• Provider outcomes

  Every 6 months beginning at the start of data collection up to 3 years

Study Arms (2)

Standard of Care

NO INTERVENTION

If patients are randomized to standard of care, they are not assigned to a Comprehensive Care Physician. They are asked to continue receiving their care as they normally would.

Comprehensive Care

EXPERIMENTAL

Patients randomized to the Comprehensive Care group are assigned to a Comprehensive Care physician and are asked to see their assigned CCP for their primary care. The patients will receive their care by the CCP in the outpatient clinic and also if they were to be hospitalized.

Other: Comprehensive Care

Interventions

Comprehensive Care OTHER

Patients will receive comprehensive medical care from their CCP in clinic and the hospital. For most patients, the ambulatory care provided by the CCP will be in our onsite medicine clinic, but for some patients with subspecialty needs the CCP may be a specialist who will care for the patient in a nearby ambulatory setting (e.g., nursing home, dialysis facility). The CCPs will also supervise the nurses, pharmacists, social workers, and others who are part of the multi-disciplinary care team. Daytime inpatient care will be provided by CCPs in conjunction with our inpatient advanced practice nurses (APNs). These APNs now work with our hospitalists, so they are experienced providing hospital care.

Comprehensive Care

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• Medicare recipients and were hospitalized at least one time in the past year

You may not qualify if:

• Non-Medicare recipients and/or were not hospitalized in the past year

Sponsors & Collaborators

• University of Chicago: lead
• University of Illinois at Chicago: collaborator
• Northwestern University: collaborator
• Endeavor Health: collaborator
• University HealthSystem Consortium: collaborator
• Rush University Medical Center: collaborator

Study Sites (1)

University of Chicago

Chicago, Illinois, 60637, United States

Location

MeSH Terms

Interventions

Comprehensive Health Care

Intervention Hierarchy (Ancestors)

Patient Care Management; Health Services Administration

Study Officials

• David Meltzer, MD, PhD

  University of Chicago

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: NONE
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: June 29, 2013
• First Posted: August 27, 2013
• Study Start: November 1, 2012
• Primary Completion: January 1, 2026
• Study Completion (Estimated): December 1, 2028
• Last Updated: December 24, 2025

Record last verified: 2025-12

Data Sharing

• IPD Sharing: Will not share

Locations

US (1)