Contra Costa Health Services Whole Person Care (CommunityConnect) Program Evaluation

NCT04000074 | Unknown

• 1 other identifier: CmCtQuantEval
• Study Type: interventional
• Target: 60,000
• Locations: 1 country
• Sites: 1

Brief Summary

Contra Costa Health System's WPC Pilot Program, titled Community Connect (CMCT), delivers case management and linkage services to high-risk Medi-Cal members in Contra Costa County, California. This program is funded under the CMS/DHCS 1115 Waiver Whole Person Care (WPC) Pilot Program through 2020. High-risk individuals from the population of Contra Costa County full-scope Medi-Cal enrollees are connected with a case manager who provides linkage services to address their social determinants of health. Program capacity is below the eligible population, so a tiered randomization strategy is used to identify enrollees and similarly risky controls (who are eligible for enrollment at later intervals). Health behaviors of enrollees and controls are tracked via electronic health records, billing claims, and other social service administrative databases to create a detailed record of post-randomization health behavior. The primary outcome of interest is avoidable utilization of emergency room and in-patient services.

Conditions

Social Determinants of Health

Keywords

Social Determinants of Health; High-Needs, High-Cost Populations; Case Management; Social Prescribing; Linkage Services

Outcome Measures

Primary Outcomes (2)

• Avoidable Emergency Room Visit Rate

  Avoidable emergency room visits are defined using the New York University algorithm applied to the primary diagnosis for the ED visit. The percent avoidability of an ED visit is defined as the sum of the percentages identified as (Emergency Care Needed Preventable, Alcohol Use, Drug Use, Psych, Non-Emergent, and Emergency Primary Care Treatable)

  Controls: From the date of identification to the earlier of 1) Date of subsequent enrollment or 2) End of Study, an average of 1 year Intervention: From the date of enrollment (or first goal) to the date of program disenrollment, average of 1 year.

• Avoidable In-Patient Visit Rate

  Avoidable In-Patient visits are identified as any visit meeting one of the relevant categories of the Agency for Healthcare Research and Quality Prevention Quality Indicators #90 (PQI-90). The criteria used were numbers 1,3,5,7,8,10,11,12,13,14,15 and 16.

  Controls: From the date of identification to the earlier of 1) Date of subsequent enrollment or 2) End of Study, an average of 1 year Intervention: From the date of enrollment (or first goal) to the date of program disenrollment, average of 1 year.

Secondary Outcomes (11)

• Specialty Care Visit Rate

  Controls: From the date of identification to the earlier of 1) Date of subsequent enrollment or 2) End of Study, an average of 1 year Intervention: From the date of enrollment (or first goal) to the date of program disenrollment, average of 1 year.

• Primary Care Visit Rate

  Controls: From the date of identification to the earlier of 1) Date of subsequent enrollment or 2) End of Study, an average of 1 year Intervention: From the date of enrollment (or first goal) to the date of program disenrollment, average of 1 year.

• Mental Health and Alcohol/Drug Visit Rates

  Controls: From the date of identification to the earlier of 1) Date of subsequent enrollment or 2) End of Study, an average of 1 year Intervention: From the date of enrollment (or first goal) to the date of program disenrollment, average of 1 year.

• Medi-Cal Retention

  Controls: From the date of identification to the earlier of 1) Date of subsequent enrollment or 2) End of Study, an average of 1 year Intervention: From the date of enrollment (or first goal) to the date of program disenrollment, average of 1 year.

• Overall Health Costs

  Controls: From the date of identification to the earlier of 1) Date of subsequent enrollment or 2) End of Study, an average of 1 year Intervention: From the date of enrollment (or first goal) to the date of program disenrollment, average of 1 year.

Study Arms (4)

Telephonic Services - Intervention

EXPERIMENTAL

Persons in this group are linked with a telephonic case manager to help address their social needs.

Behavioral: Telephonic Services

Telephonic Services - Control

NO INTERVENTION

Persons in this group are similar in risk to those in the 'Telephonic Services - Intervention' arm, but are not linked with a case manager.

In-Person Services - Intervention

EXPERIMENTAL

Persons in this group are linked with an in-person case manager who makes home visits to help address their social needs.

Behavioral: In-Person Services

In-Person Services - Control

NO INTERVENTION

Persons in this group are similar in risk to those in the In-Person Services - Intervention' arm, but are not linked with a case manager.

Interventions

Telephonic Services BEHAVIORAL

Provides linkage services to local programs that address the social determinants of health remotely via phone, email and/or fax

Also known as: CmCt Tier II

Telephonic Services - Intervention

In-Person Services BEHAVIORAL

Provides linkage services to local programs that address the social determinants of health directly to the client during face-to-face visits as well as remotely via phone, email, etc.

Also known as: CmCt Tier I

In-Person Services - Intervention

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: Yes
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• Full Scope MediCal members administered by Contra Costa Health Services and in Contra Costa Regional Medical Centers network.
• Having sufficiently high estimated risk of future avoidable utilization to rank within the top 25,000 of the potentially eligible population

You may not qualify if:

• Not case managed under other locally administered plans
• Not living outside Contra Costa County
• Not in detention for the past month
• Not hospitalized for the past month
• Not previously enrolled in the program (some disenrollment reasons allow for subsequent re-eligibility)

Sponsors & Collaborators

• Contra Costa Health Services: lead

Study Sites (1)

Contra Costa Whole Person Care Program

Concord, California, 94520, United States

RECRUITING

Related Publications (2)

• Fleming MD, Guo C, Knox M, Brown DM, Hernandez EA, Brewster AL. Impact of Social Needs Case Management on Use of Medical and Behavioral Health Services: Secondary Analysis of a Randomized Controlled Trial. Ann Intern Med. 2023 Aug;176(8):1139-1141. doi: 10.7326/M23-0876. Epub 2023 Aug 8. No abstract available.

  PMID: 37549385 DERIVED

• Brown DM, Hernandez EA, Levin S, De Vaan M, Kim MO, Lynch C, Roth A, Brewster AL. Effect of Social Needs Case Management on Hospital Use Among Adult Medicaid Beneficiaries : A Randomized Study. Ann Intern Med. 2022 Aug;175(8):1109-1117. doi: 10.7326/M22-0074. Epub 2022 Jul 5.

  PMID: 35785543 DERIVED

Study Design

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

Model Details: Potential enrollees are identified from a predictive model operating on an administrative database. There are two types of service delivery systems: in-home visits and telephonic. Each month, a population of the highest risk clients are identified as eligible for the home-visit and a population of elevated risk clients are identified as eligible for telephonic services. From these populations, sufficient new enrollees are identified to reach program capacity, and twice this number of controls. Persons previously identified as controls are eligible for enrollment into the program in subsequent months

Study Record Dates

• First Submitted: February 20, 2019
• First Posted: June 27, 2019
• Study Start: January 1, 2017
• Primary Completion: December 31, 2020
• Study Completion: December 31, 2021
• Last Updated: June 27, 2019

Record last verified: 2019-06

Locations

US (1)