IT to Support Integration of Social Determinant of Health Services to Reduce Avoidable Emergency Department Visits

Northern New York Rural Behavioral Health Institute

Status: Unknown

Conditions: Mental Health Issue; Substance Use Disorders

Treatments: Behavioral: Peer Integrated Care Services

Study type: Interventional

Funder types: Other

Identifiers

NCT04125433

NCBHNPIC

Details and patient eligibility

About

Working through regional Accountable Care Organizations (ACO) the sponsor will establish a 2-year pilot project to demonstrate that early recognition and intervention in the various Social Determinant of Health (SDoH) domains can reduce avoidable Emergency Department (ED) visits by high utilizers. The regional ACO's will contract with Medicaid Managed Care Plans to assign traditional high ED utilizing members to the pilot project. Members will be offered enhanced peer facilitated care management services connecting members with available SDoH community based services. Members fitting our eligibility criteria will self-select by way of completing a pilot project consent form.

Full description

The project employs a two level intervention to include Peer Support Specialist (PSS) and Community Health Advocate (CHA). Contact and engagement with participating members will be through both direct intervention in the emergency department by Peer Support Specialist (the peer) as well as in the community for prevention visits and follow up by both the peer and Community Health Advocate. These well-positioned Peers and Community Health Advocates will address Behavioral and Social Determinants of Health (SDoH) concerns through a highly coordinated intervention supported by a common IT Medicaid member tracking platform. This research project will determine the feasibility of deploying a single shared IT platform that will include referral, appointment completion, and intervention outcome data. Project staff will develop a trusting relationship with the members and will improve member access and engagement with community-based services. The project will also seek to determine the impact on total cost of care through redirecting study participants to community resources that are more appropriate, and less expensive than return visits to the emergency department.

Enrollment: 400 estimated patients

Sex: All

Ages: 18 to 65 years old

Volunteers: No Healthy Volunteers

Inclusion criteria

• Adults age 18 to 65
• New York State Medicaid Managed Care Members
• Have utilized emergency department services 6 or more times in a 12-month period
• Have been assigned to the Pilot Project by their Medicaid Managed Care Plan

Exclusion criteria

• Individuals not assigned by a Managed Care Organization meeting the above criteria

Trial design

Primary purpose: Supportive Care

Allocation: N/A

Interventional model: Single Group Assignment

Masking: None (Open label)

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400 participants in 1 patient group

Medicaid Emergency Department High Utilizers

Experimental group

Description:

This Arm will include the following individuals * Up to 400 Adults age 18 to 65 * New York State Medicaid Managed Care Members * Have utilized emergency department services 6 or more times in a 12-month period * Have been assigned to the Pilot Project by their Medicaid Managed Care Plan

Treatment:

Behavioral: Peer Integrated Care Services