NCT05820295

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

• Status: Completed
• Phase: N/A
• Study type: Interventional
• Enrollment: 400 (actual)
• Sponsor: Weill Medical College of Cornell University · Academic / Other
• Sex: All
• Age: 65 Years
• Healthy volunteers: Not accepted

Summary

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.

Detailed 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.

Conditions

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

Interventions

Type	Name	Description
BEHAVIORAL	Care coordination delivered based on perceived need	If patients in intervention group report on the survey that they experience difficulty coordinating care among their providers, the patient will be selected for care management services. Those services will attempt to address the problems with care coordination that the proxy reported.
BEHAVIORAL	Care coordination delivered based on usual care (e.g. discharge from hospital)	If a patient is discharged from a hospital, the patient will be selected for care management services.

Timeline

• Start date: 2023-05-17
• Primary completion: 2024-05-31
• Completion: 2024-07-11
• First posted: 2023-04-19
• Last updated: 2025-09-04
• Results posted: 2025-09-04

Locations

1 site across 1 country: United States