Improving How Older Adults at Risk for Cardiovascular Outcomes Are Selected for Care Coordination

Weill Cornell Medicine (WCM)

Status: Completed

Conditions: Ischemic Heart Disease; Hypertension; Atrial Fibrillation; Stroke; Hyperlipidemias; Diabetes Mellitus; Transient Ischemic Attack; Myocardial Infarction; Cardiovascular Diseases; Heart Failure

Treatments: Behavioral: Care coordination delivered based on perceived need; Behavioral: Care coordination delivered based on usual care (e.g. discharge from hospital)

Study type: Interventional

Funder types: Other; Other U.S. Federal agency

Identifiers

NCT05820295

1K18HS029255-01 (U.S. AHRQ Grant/Contract)

22-09025263

Details and patient eligibility

About

This pragmatic clinical trial embedded in an accountable care organization will determine the comparative effectiveness of two approaches for assigning care coordinators to older adults at risk for cardiovascular outcomes. The hypothesis is that assigning care coordinators to older adults based on perceived need will be more effective at preventing emergency department visits and hospitalizations compared to usual care.

Full description

This project will use a pragmatic clinical trial embedded in an accountable care organization (ACO) to determine the comparative effectiveness of two different approaches for selecting older adults at risk for cardiovascular outcomes to receive support from care coordinators: (1) an approach that assigns older adults to care coordinators based on self-reported difficulty with care coordination, or (2) usual care, which generally assigns older adults to care coordinators after hospital discharge, regardless of perceived need. The investigators will include community-dwelling Medicare beneficiaries ≥65 years old with cardiovascular disease (CVD) or 1 or more CVD risk factors who have been attributed to the NewYork Quality Care ACO and who have fragmented care. The investigators will randomize the participants into two groups. This study is highly pragmatic, and the intervention is sustainable and scalable. Moreover, the proposed approach has the potential to improve care delivery and outcomes for older adults at risk for cardiovascular outcomes.

Enrollment: 400 patients

Sex: All

Ages: 65+ years old

Volunteers: No Healthy Volunteers

Inclusion criteria

• Medicare beneficiaries 65 years and older,
• Attributed to the NewYork Quality Care accountable care organization,
• Are community-dwelling,
• Have cardiovascular disease or 1 or more cardiovascular risk factors, and
• Had highly fragmented ambulatory care in the prior year (defined as a reversed Bice-Boxerman Index greater than or equal to 0.85)

Exclusion criteria

• Those who reside in long-term care or nursing home facilities (based on addresses in Medicare claims)
• Enrolled in home hospice
• Dementia (as measured in claims using the Bynum Standard 1-year definition)

Trial design

Primary purpose: Health Services Research

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: None (Open label)

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400 participants in 2 patient groups

Intervention

Experimental group

Description:

The intervention group will assign care coordinators to individuals based on perceived need for assistance with care coordination. Perceived need will be measured through a proxy's responses to a previously validated telephone survey on perceptions of care coordination.

Treatment:

Behavioral: Care coordination delivered based on perceived need

Control

Active Comparator group

Description:

Usual care assigns patients to care coordinators in response to a discharge from a hospital or a direct referral from a physician.

Treatment:

Behavioral: Care coordination delivered based on usual care (e.g. discharge from hospital)