N/A
Completed N=800
Health Care Hotspotting: A Randomized Controlled Trial
High Utilizers of Hospital Care
Source: ClinicalTrials.gov NCT02090426 ↗
Enrolled (actual)
800
Serious AEs
0.0%
Results posted
Mar 2020
Primary outcomePrimary: Any Hospital Readmission — 240; 245 Participants
Summary
This trial investigates the value created by the highly innovative Camden Coalition of Healthcare Providers' Care Management Program: Link2Care. The program targets "super-utilizers" of the health care system - specifically adults with 2 or more hospitalizations in the last six months 2 or more chronic conditions, and 5 or more outpatient medications - with intensive case management services. In particular, a team of nurses, social workers, community health workers and health coaches, supported by real-time data of healthcare utilization, perform home visits, accompany patients to doctor visits, and help patients enroll in social-service programs. This approach aims to improve the self-sufficiency of patients in navigating the healthcare and social-service systems and has the potential to reduce healthcare costs and improve patient health.
Outcome Measures
| Outcome | Result | p-value |
|---|---|---|
| PRIMARY Any Hospital Readmission |
240; 245 | — |
| SECONDARY Any Emergency Department Use |
— | — |
| SECONDARY Any Hospital Use (Inpatient or ED) |
— | — |
| SECONDARY Inpatient Readmission From the ED |
— | — |
| SECONDARY Inpatient Readmission Not From the ED |
— | — |
| SECONDARY Number of Readmissions |
— | — |
| SECONDARY Had 2+ Readmissions |
141; 143 | — |
| SECONDARY Number of Days in the Hospital |
9.95; 9.36 | — |
| SECONDARY Hospital Charges |
114,768; 116,422 | — |
| SECONDARY Hospital Receipts |
17,650; 18,130 | — |
Eligibility Criteria
Inclusion Criteria
Patients must satisfy the following criteria based on the records from the index event:
- Is currently admitted to Cooper or Lourdes hospitals (still in hospital for recruitment)
- Resides in the following zip codes: 08101 (PO zip code), 08102-08105, 08107s, 08110
- Is 19-80 years old
- Has >=2 hospital admissions in the past 6 months (to Camden area hospitals in the Health Information Exchange )
- Has >=2 chronic conditions
Patients must meet at least three of the following criteria based largely on the electronic medical record:
- Has >=5 outpatient medications
- Has difficulty accessing services
- Lacks social support
- Has mental health co-morbidity
- Is actively using drugs
- Is homeless
Exclusion Criteria
- Already subject in RCT (treatment or control)
- Deceased or discharged prior to triage or recruitment
- Uninsured
- Cognitively impaired
- Oncology patient
- Index hospitalization is for: a surgical procedure for an acute problem, complications of a progressive chronic disease with limited treatments, or mental health issue only with no co-morbid conditions
Data sourced from ClinicalTrials.gov (NCT02090426). Outcome figures and adverse-event rates are extracted automatically from the registry's posted results and are provided for clinician reference, not as a substitute for the primary publication. Informational only — not medical advice.