Evaluation of a Personalized Care Management Program for High Hospital Utilizers

NCT04727567 | Completed

• 2 other identifiers: IRB0008249804-20-10E
• Study Type: observational
• Target: 454
• Locations: 1 country
• Sites: 1

Brief 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.

Conditions

Comorbidities and Coexisting Conditions

Keywords

Patient Care Management; Patient Hospital Admissions

Outcome Measures

Primary Outcomes (1)

• 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 Outcomes (17)

• Number of inpatient hospital encounters over a 6 month period

  6 months

• Combined Inpatient and Observational hospital encounters - Atrium only

  6 months

• Combined Inpatient and Observational hospital encounters - non-Atrium included

  6 months

• Combined Inpatient and Observational hospital encounters - Atrium only

  12 month

• Combined Inpatient and Observational hospital encounters - non-Atrium included

  12 month

Study Arms (2)

Multiple Visit Patient (MVP) Program

The MVP 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: customized care plan developed for each patient at the time of enrollment routine, virtual health monitoring and collaborative care management team-based review personalized navigation and coordination across multidisciplinary Atrium Health services, as needed. Education, health coaching, and support via telephonic and in-person interactions, as needed.

Usual Care

Atrium Health standard of care. Patient's post-discharge usual care depends on the inpatient care management assessment at last hospital admission. Patients can be discharged to home and receive no further care, or home with home health, or to a skilled nursing facility (SNF) or another type of Continuing Care facility. Patients can be referred to advanced illness management, hospice, and Community Care Partners by the inpatient care manager. Patient can be referred to Ambulatory Care Management for care management also via telehealth, by a primary care physician or the Transitions Clinic.

Eligibility Criteria

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

Study Population

Patients included in the evaluable population for this project, will have their data inform the final outcomes assessment. All patients who meet the inclusion and exclusion criteria in both groups will be assessed for the primary outcome (intent to treat).

You may qualify if:

• years of age or older
• or more inpatient hospital visits across Atrium Health Metro hospitals in 2019

You may not qualify if:

• 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

Sponsors & Collaborators

• Wake Forest University Health Sciences: lead

Study Sites (1)

Atrium Health - Care Management Program

Charlotte, North Carolina, 28203, United States

Location

Study Officials

• Alica Sparling, PhD

  Wake Forest University Health Sciences

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: observational
• Observational Model: CASE CONTROL
• Time Perspective: PROSPECTIVE
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: January 12, 2021
• First Posted: January 27, 2021
• Study Start: April 23, 2020
• Primary Completion: May 1, 2021
• Study Completion: August 31, 2021
• Last Updated: April 22, 2022

Record last verified: 2021-09

Data Sharing

• IPD Sharing: Will not share

Locations

US (1)