Connecting Low-Income Adults to Primary Care After Inpatient Discharge

NCT05567224 | Completed

• 1 other identifier: 221128
• Study Type: observational
• Target: 200
• Locations: 1 country
• Sites: 1

Brief Summary

Healthcare systems and insurers have tried to reduce costs by improving the care and coordination provided to patients with high healthcare spending. Often termed, "hotspotting", these interventions seek to lower costs by reducing care provided in fragmented, high-cost settings, including the emergency department and inpatient settings, by addressing the social determinants of health and improving patients' access to lower-cost, ambulatory settings. Vanderbilt University Medical Center (VUMC), in collaboration with Tennessee's Medicaid agency (TennCare), is piloting a program to reduce costs and improve the quality of care provided to high-risk TennCare enrollees by referring them from inpatient settings to VUMC primary care services. This study seeks to evaluate this pilot by comparing outcomes between Medicaid patients referred to VUMC primary care services and similar Medicaid patients not referred to VUMC primary care services using data from surveys and administrative sources, including electronic health records and health insurance claims.

Conditions

Health Care Utilization; Health Care Seeking Behavior

Keywords

Health Care Costs; Hospitalizations; Emergency Department Use; Health Care Accessibility; Medicaid; Low-income populations

Outcome Measures

Primary Outcomes (1)

• Number of Inpatient Admissions

  How many times the participant is hospitalized within the specified time period

  30, 60, 90, 180, and 360 days

Secondary Outcomes (5)

• Number of Emergency Department Visits

  30, 60, 90, 180, and 360 days

• Number of Primary Care Visits

  30, 60, 90, 180, and 360 days

• Average Health Care Spending

  30, 60, 90, 180, and 360 days

• Average Self-reported Health Status

  30, 60, 90, 180, and 360 days

• Average of Disease Specific Outcomes

  30, 60, 90, 180, and 360 days

Study Arms (2)

Pilot Group

This group of TennCare recipients will be referred to VUMC primary care services and will be allowed to utilize these services for at least two years. Those referred to VUMC primary care services will be those who belong to the two of state's three Medicaid Managed Care plans who have agreed to participate in this pilot.

Other: Access to primary care services

Control Group

This group of TennCare recipients will not be referred to VUMC primary care services and will receive care as usual. Those not referred to VUMC primary care services will be those who belong to one of the state's three Medicaid Managed Care plans who has not agreed to participate in this pilot.

Interventions

Access to primary care services OTHER

Those in the pilot group will be referred to primary care services and allowed to utilize them for at least two years. Primary care services include access to a primary care physician, medical management, and other tasks typically performed by a general practitioner. Those referred to primary care services will not have access to other VUMC outpatient services.

Pilot Group

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 age 18 or older who are currently enrolled in Tennesee's Medicaid program (TennCare) and who are presenting in VUMC's inpatient setting, and who report no active relationship with a primary care doctor.

You may qualify if:

• Age 18 or older
• Currently enrolled in Tennessee's Medicaid Program (TennCare)
• Presenting in VUMC's inpatient setting
• Reporting no active relationship with a primary care doctor
• Lives in Davidson County, Tennessee, or a surrounding county

You may not qualify if:

• Patients discharged to a setting other than the community (e.g. to a Skilled Nursing Facility)

Sponsors & Collaborators

• Vanderbilt University Medical Center: lead

Study Sites (1)

Vanderbilt University Medical Center

Nashville, Tennessee, 37232, United States

Location

MeSH Terms

Conditions

Patient Acceptance of Health Care

Condition Hierarchy (Ancestors)

Treatment Adherence and Compliance; Health Behavior; Behavior

Study Design

• Study Type: observational
• Observational Model: OTHER
• Time Perspective: PROSPECTIVE
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Assistant Professor, Department of Health Policy

Study Record Dates

• First Submitted: September 30, 2022
• First Posted: October 5, 2022
• Study Start: December 15, 2022
• Primary Completion: April 1, 2025
• Study Completion: April 1, 2025
• Last Updated: April 29, 2025

Record last verified: 2025-02

Data Sharing

• IPD Sharing: Will not share

Locations

US (1)