Connecting Low-Income Adults to Primary Care After Inpatient Discharge

Vanderbilt University Medical Center

Status: Completed

Conditions: Health Care Seeking Behavior; Health Care Utilization

Treatments: Other: Access to primary care services

Study type: Observational

Funder types: Other

Identifiers

NCT05567224

221128

Details and patient eligibility

About

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.

Enrollment: 200 patients

Sex: All

Ages: 18+ years old

Volunteers: No Healthy Volunteers

Inclusion criteria

• 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

Exclusion criteria

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

Trial design

200 participants in 2 patient groups

Pilot Group

Description:

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.

Treatment:

Other: Access to primary care services

Control Group

Description:

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.