N/A
N=800
Health Care Hotspotting: A Randomized Controlled Trial
High Utilizers of Hospital Care
Bottom Line
View on ClinicalTrials.gov: NCT02090426 ↗Enrolled (actual)
800
Serious AEs
0.0%
Results posted
Mar 2020
Primary outcome: Primary: Any Hospital Readmission — 240; 245 Participants
Study Design & Population
- Study type
- Interventional
- Phase
- N/A
- Interventions
- Link2Care (Other)
- Age
- Adult, Older Adult · 19+ yrs
- Sex
- All
- Sponsor
- Abdul Latif Jameel Poverty Action Lab
- Primary completion
- Oct 2018
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 | — |
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.
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.