Evaluating the Impact of a Supportive Care Program

NCT04971278 | Completed

• 1 other identifier: QI-High Risk
• Study Type: observational
• Target: 1,201
• Locations: 1 country
• Sites: 1

Brief Summary

NYU's High Risk Program targets patients who may be more likely to have increased hospitalization due to health conditions that may cause death in the near future. Community Health Workers, a home visiting doctor service, a supportive care nurse, and behavioral health specialist engage the population to address a range of biopsychosocial needs with end goal in increasing support in the community and engaging palliative and hospice care when appropriate to prevent hospital readmissions, shorten length of stay, reduce hospital utilization, and decrease overall patient cost with a focus on hospital spend.

Conditions

Patient Engagement; Morality

Outcome Measures

Primary Outcomes (1)

• Rate of Advance Care Planning note creation

  How many and how often are ACP notes written for patients

  2 years

Study Arms (4)

HealthFirst Intervention

Patients attributed to HealthFirst who will receive the intervention

Behavioral: Supportive care program

HealthFirst Control

Patients attributed to HealthFirst who will not receive the intervention

Mortality Model Intervention

Patients who are identified as High Risk by the mortality predictive model and who receive the intervention.

Behavioral: Supportive care program

Mortality Model Control

Patients who are identified as High Risk by the mortality predictive model and who do not receive the intervention.

Interventions

Supportive care program BEHAVIORAL

Community Health Workers, a home visiting doctor service, a supportive care nurse, and behavioral health specialist engage the population to address a range of biopsychosocial needs with end goal in increasing support in the community and engaging palliative and hospice care when appropriate to prevent hospital readmissions, shorten length of stay, reduce hospital utilization, and decrease overall patient cost with a focus on hospital spend.

HealthFirst Intervention; Mortality Model Intervention

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Age Groups: Adult (18-64), Older Adult (65+)
• Sampling Method: Probability Sample

Study Population

NYU Langone adult patients (\>18 years old) at or above the 75th percentile on NYU's mortality model currently attributed to one of DSRIP's value based contracts.

You may qualify if:

• years or older
• at or above the 75th percentile on the Mortality Model
• Attributed to a value based contract

You may not qualify if:

• Less than 18 years of age
• Below the 75th percentile on the Mortality Model
• Not attributed to a value based contract

Sponsors & Collaborators

• NYU Langone Health: lead

Study Sites (1)

NYU Langone Health

New York, New York, 10016, United States

Location

MeSH Terms

Conditions

Patient Participation

Condition Hierarchy (Ancestors)

Patient Acceptance of Health Care; Treatment Adherence and Compliance; Health Behavior; Behavior

Study Officials

• Leora Horwitz, MD

  NYU Langone Health

  PRINCIPAL INVESTIGATOR

Study Design

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

Study Record Dates

• First Submitted: July 14, 2021
• First Posted: July 21, 2021
• Study Start: November 7, 2019
• Primary Completion: February 28, 2022
• Study Completion: September 22, 2022
• Last Updated: July 11, 2023

Record last verified: 2023-07

Locations

US (1)