NCT04727567

Evaluation of a Personalized Care Management Program for High Hospital Utilizers

Effect of a Personalized Care Management Program on Hospital Inpatient Stays Among High Utilizers: A Randomized Clinical Trial

• Status: Completed
• Phase: —
• Study type: Observational
• Enrollment: 454 (actual)
• Sponsor: Wake Forest University Health Sciences · Academic / Other
• Sex: All
• Age: 18 Years
• Healthy volunteers: Not accepted

Summary

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.

Detailed 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.

Conditions

• Comorbidities and Coexisting Conditions

Timeline

• Start date: 2020-04-23
• Primary completion: 2021-05-01
• Completion: 2021-08-31
• First posted: 2021-01-27
• Last updated: 2022-04-22

Locations

1 site across 1 country: United States