3000 Participants Needed

Comprehensive Care Models for Medicare Patients

Age: 18+
Sex: Any
Trial Phase: Academic
Sponsor: University of Chicago
No Placebo GroupAll trial participants will receive the active study treatment (no placebo)

What You Need to Know Before You Apply

What is the purpose of this trial?

This randomized trial is evaluating whether socioeconomically disadvantaged Medicare patients at increased risk of hospitalization experience fewer hospitalization if those patients are offered care in: 1) ACCT, where patients receive care from different physicians in the hospital and the clinic settings and have access to nurse and social worker care coordination services, 2) CCP where patients receive care from one physician in the inpatient and outpatient settings or 3) C4P which adds screening of unmet social needs, community health worker support and arts and culture programming to CCP. The study will determine how these programs affect patient activation and engagement in care, satisfaction with care, general health and mental health, and goal attainment.

Will I have to stop taking my current medications?

The trial information does not specify whether you need to stop taking your current medications.

Is the Comprehensive Care Models for Medicare Patients program safe for humans?

The research articles do not provide specific safety data for the Comprehensive Care Models for Medicare Patients program, but they discuss efforts to improve care coordination and reduce hospital readmissions, which are generally aimed at enhancing patient safety.12345

How is the Comprehensive Care Models for Medicare Patients treatment different from other treatments?

This treatment is unique because it combines different care models to provide both inpatient and outpatient care by the same physician, aiming to improve coordination and outcomes for patients at high risk of hospitalization. It focuses on comprehensive care through a team approach, which is not commonly found in standard treatments.36789

What data supports the effectiveness of the treatment Ambulatory Care Coordinator Team (ACCT), Comprehensive Care Community & Culture Program (C4P), Comprehensive Care Physician Program (CCP)?

The Comprehensive Care Physician model, which is part of the treatment, focuses on improving care coordination for patients at high risk of hospitalization by having the same physician provide both hospital and outpatient care. This approach aims to improve patient outcomes and reduce costs, although evidence of its effectiveness was still being assessed as of the last report.3561011

Are You a Good Fit for This Trial?

This trial is for socioeconomically disadvantaged Medicare patients who have been hospitalized once in the past 2 years or are currently in the emergency department. It's designed to see if different care approaches can reduce hospital visits.

Inclusion Criteria

Must have Medicare Part A and Part B
Must have been hospitalized once in the past 2 years or be in emergency department at time recruitment is initiated

Exclusion Criteria

None

Timeline for a Trial Participant

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Treatment

Participants are assigned to one of three care models: ACCT, CCP, or C4P, and receive care coordination and support services

1 year

Follow-up

Participants are monitored for hospitalization rates, patient activation, engagement, satisfaction, and health outcomes

1 year

Extension

Optional continuation of care coordination and support services for participants who wish to continue beyond the initial study period

Up to 4.5 years

What Are the Treatments Tested in This Trial?

Interventions

  • Ambulatory Care Coordinator Team (ACCT)
  • Comprehensive Care Community & Culture Program (C4P)
  • Comprehensive Care Physician Program (CCP)
Trial Overview The study compares three care models: ACCT with team-based coordination, CCP with consistent care from one physician, and C4P which adds social support and cultural programs to CCP. The impact on health, satisfaction, and goal attainment will be measured.
How Is the Trial Designed?
3Treatment groups
Active Control
Group I: Ambulatory Care Coordinator Team (ACCT)Active Control1 Intervention
Patients randomized to ACCT receive care from different doctors in clinic and in the hospital. ACCT patients who have been hospitalized twice, had 4 emergency department (ED) visits in the last year or are referred by their primary care physician are offered ACCT care coordination services (ACCT-CC) from nurses and social workers who manage their care with the larger clinical team. Patients are graduated from ACCT if the ACCT team thinks they are no longer high risk.
Group II: Comprehensive Care Physician (CCP)Active Control1 Intervention
Patients randomized to the CCP group are assigned to a Comprehensive Care Physician and are asked to see their assigned CCP for their primary care. The patients receive their care from the same CCP in the outpatient clinic and also if they were to be hospitalized.
Group III: Comprehensive Care, Community & Culture Program (C4P)Active Control1 Intervention
Patients randomized to C4P receive care from a CCP in both the hospital and the clinic as well as the following: 1) systematic screening of 17 domains of unmet social needs, 2) access to a community health worker and 3) access to community-based arts and culture programming.

Find a Clinic Near You

Who Is Running the Clinical Trial?

University of Chicago

Lead Sponsor

Trials
1,086
Recruited
844,000+

Patient-Centered Outcomes Research Institute

Collaborator

Trials
592
Recruited
27,110,000+

Published Research Related to This Trial

The Johns Hopkins Community Health Partnership (J-CHiP) effectively improved care coordination for high-risk patients by implementing redesigned acute care delivery and seamless transitions of care, targeting adults discharged from hospitals and those receiving primary care in the community.
Key interventions included risk screening, multidisciplinary care planning, and collaboration with skilled nursing facilities, which collectively enhanced patient engagement and strengthened partnerships with community organizations, ultimately aiming to improve health outcomes.
Implementation of a comprehensive program to improve coordination of care in an urban academic health care system.Hsiao, YL., Bass, EB., Wu, AW., et al.[2018]
Care coordination programs for high-risk Medicaid patients can improve outcomes, but there are significant unmet needs related to trauma, mental health, and executive function challenges that require additional support.
Focus groups revealed that while provider communication is generally positive, enhancing peer-to-peer support and addressing specific patient needs can further improve the effectiveness of care coordination efforts.
The patient perspective: utilizing focus groups to inform care coordination for high-risk medicaid populations.Sheff, A., Park, ER., Neagle, M., et al.[2018]
Implementing a proactive telehealth follow-up system for geriatric patients at the Tennessee Valley Healthcare System led to a significant reduction in 30-day all-cause readmissions, decreasing from 21% to 13% during the intervention period.
The use of Plan, Do, Study, Act (PDSA) cycles and data sharing among care teams improved care coordination and accountability, contributing to better management of high-risk patients.
The GeriPACT Initiative to Prevent All-Cause 30-Day Readmission in High Risk Elderly.Powers, JS., Abraham, L., Parker, R., et al.[2021]

Citations

Redesigning care for patients at increased hospitalization risk: the Comprehensive Care Physician model. [2021]
Poisoning and toxic effects of drugs: a critical pathway for improving outcomes. [2004]
Attaining superior outcomes with joint replacement patients. [2019]
Implementation of a comprehensive program to improve coordination of care in an urban academic health care system. [2018]
The patient perspective: utilizing focus groups to inform care coordination for high-risk medicaid populations. [2018]
Evaluation of Clinical Pharmacist Services in a Transitions of Care Program Provided to Patients at Highest Risk for Readmission. [2023]
Optimizing the Care Coordinator Role in Primary Care: A Qualitative Case Study. [2018]
The GeriPACT Initiative to Prevent All-Cause 30-Day Readmission in High Risk Elderly. [2021]
The focus of improved profit. [2019]
10.United Statespubmed.ncbi.nlm.nih.gov
Implementation of the Chronic Care Model to Reduce Disparities in Hypertension Control: Benefits Take Time. [2021]
Benefits and limitations of implementing Chronic Care Model (CCM) in primary care programs: A systematic review. [2018]
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