Evaluation of a Personalized Care Management Program for High Hospital Utilizers

Wake Forest University (WFU)

Status: Completed

Conditions: Comorbidities and Coexisting Conditions

Study type: Observational

Funder types: Other

Identifiers

NCT04727567

04-20-10E

IRB00082498

Details and patient eligibility

About

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.

Full description

The list of patients with four or more inpatient hospital visits in 2019 will be pulled from the Atrium Health electronic data warehouse (EDW) by IAS Clinical Quality Analytics, and eligibility for the MVP program of patients on this list will be determined by the Population Health's Care Management team based on predefined eligibility criteria. IAS CORE will randomize eligible participants into one of two groups: 1) MVP program; or 2) usual care.

Population Health's Multiple Visit Patient (MVP) care management 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:

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

The control group will receive usual care.

Upon completion of the 12-month period during which outcomes data will be accrued, the study will evaluate whether 12-month participation in the MVP program care management program, compared to usual care, reduced inpatient hospital use.

Enrollment: 454 patients

Sex: All

Ages: 18+ years old

Volunteers: No Healthy Volunteers

Inclusion criteria

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

Exclusion criteria

• 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

Trial design

454 participants in 2 patient groups

Multiple Visit Patient (MVP) Program

Description:

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

Description:

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.