N/A N=25,507 Minnesota Care Coordination Effectiveness Study
Chronic Disease · Multi-morbidity · Care Coordination
Primary: Change in Composite Measure of Care Quality — 7.0; 4.5; 5.9; 5.9 Change in percent — p=0.19
Clinical Trial Search
Completed trials with posted results — search by concept, filter by the parameters that matter at the bedside.
N/A N=63 Pilot Study to Improve Care Coordination
Chronic Illness
Primary: Patient Perceived Continuity of Care From Multiple Providers- Management Continuity — -0.65; 4.0 units on a scale — p=0.02
N/A N=4,322 Care Coordination for Complex Cancer Survivors in an Integrated Safety Net System
Breast Cancer · Colorectal Cancer
Primary: Proportion of Complex Cancer Survivors Meeting Quality of Care Guidelines for Chronic Conditions and Follow-up Cancer Surveillance
N/A N=64,382 Care Coordination for Children With Disabilities
Experiences With Health Care Coordination
Primary: Percent of Caregivers Who Reported That Their Child Has a Designated Care Coordinator — 864 Participants
N/A N=44 Cirrhosis Medical Home
Cirrhosis, Liver
Primary: Enrollment Rate — 20; 20 Participants
N/A N=4,965 Coordination Toolkit and Coaching Project
Coordination, Administrative
Primary: Health Care System Hassles Scale — 5.20; 4.71; 4.78; 4.30 units on a scale
N/A N=385 Improving How People Living With Dementia Are Selected for Care Coordination
Dementia
Primary: Number of Emergency Department Visits or Hospital Admissions — 0.33; 0.35 events per 100 person-days alive
Phase 3 N=835 Virtual Continuity and Its Impact on Complex Hospitalized Patients' Care
Automated Communication Tools · Complex Medical Patients
Primary: Medication Errors at Hospital Discharge — 645; 359 Errors
N/A N=400 Improving How Older Adults at Risk for Cardiovascular Outcomes Are Selected for Care Coordination
Cardiovascular Diseases · Myocardial Infarction · Atrial Fibrillation
Primary: Number of Emergency Department Visits or Hospital Admissions — 0.25; 0.21 events per 100 person-days alive
N/A N=1,400 Integrated Care (IC) Models for Patient-Centered Outcomes
Diabetes · Asthma · Chronic Obstructive Pulmonary Disease
Primary: Patient Activation — 61.87; 63.73; 63.82; 63.15 score on a scale — p=0.0211
N/A N=1,679 Relative Patient Benefits of a Hospital-PCMH Collaboration Within an ACO to Improve Care Transitions
Adverse Events · Readmissions · Patient Engagement
Primary: Proportion of Participants With an Adverse Event Within 30 Days After Index Discharge Date — 0.18; 0.23 proportion of participants — p=0.02
N/A N=800 Health Care Hotspotting: A Randomized Controlled Trial
High Utilizers of Hospital Care
Primary: Any Hospital Readmission — 240; 245 Participants
N/A N=796 Regional Data Exchange to Improve Care for Veterans After Non-VA Hospitalization
Patient Readmission · Adverse Drug Event · Cost
Primary: Number of Participants With Hospital Readmission — 23; 21; 35 Participants
N/A N=168,477 Consumer Health IT Tools: Impact on Experience, Access, and Outcomes for Patients With Complex Chronic Conditions
Chronic Disease · Patient Outcome Assessment · Electronic Health Records
Primary: Number of Ambulatory Care Sensitive Conditions (ACSC) Hospitalizations. Portal Users vs Those Who Are Not Portal Users — 6.2; 7.0 hospitalizations/1000 participants/month
N/A N=25 Living With Multimorbidity: CO-ORDINATE Program
Multimorbidity · Quality of Life · Symptom Management
Primary: Symptom Burden Assessed by Edmonton Symptom Assessment System (ESAS) Score - Pain — 5; 4; 5 score on a scale
N/A N=750 Aligning Patients and Their Primary Care Providers
Primary Health Care · Quality of Health Care · Comorbidity
Primary: Aggregate Measure of Guideline-Based Clinical Care Gaps — 184; 210 Participants
N/A N=127 Rural Options At Discharge Model of Active Planning
All Causes Hospital Admissions
Primary: Hospital Re-admissions Analyzed by Poisson Regression — 17; 4; 21; 5 Hospital Readmission — p=0.030
N/A N=263 Home Based Care Transitions Tailored by Cognition and Patient Activation
Chronic Disease
Primary: Health Care Utilization — 7; 8; 4; 3 events
N/A N=331 Improving Care for Children With Complex Needs
Medically Complex Children · Care Coordination · Case Manager
Primary: Cost of Care — 71692; 70618; 37,677; 56702 US Dollars
N/A N=1,979 Paramedic Coached ED Care Transitions to Help Older Adults Maintain Their Health
Emergencies · Aging
Primary: Number of Participants Returning to the ED Within 30 Days of the Original ED Visit — 84; 69; 51; 113 Participants
N/A N=29,134 Evaluating the Impact of Patient-Centered Oncology Care
Neoplasms
Primary: Change in Patient Experience From Baseline to Follow up — 90.1; 90.0; 92.8; 92.4 units on a scale — p=.025
N/A N=18,268 Improving Chronic Disease Management With Pieces
Chronic Kidney Disease · Diabetes · Hypertension
Primary: All Cause Hospitalizations for Patients With a Triad of Chronic Kidney Disease, Diabetes and Hypertension — 20.7; 21.12 percentage of participants hospitalized
N/A N=66 Care Coordination System for People With Dementia
Alzheimer Disease · Dementia · Dementia Alzheimers
Primary: Change in Baseline Burden and Stress of Caregivers Over 3 Months — -52.0; -31.9 percentage change
N/A N=1,376 Coordinated Emergency Department Transitions
Alzheimer Disease or Associated Disorder
Primary: Percent of Eligible Emergency Department Visits With Completed Outreach — 547; 304 Emergency Department Visits
N/A N=264 Patient Priority Care for Older Adults With Multiple Chronic Conditions
Multiple Chronic Conditions
Primary: Treatment Burden — 11.9; 11.6; 12.7; 17.9 score on a scale
N/A N=514 Discharge Information and Support for Patients Receiving Outpatient Care in the Emergency Department
Multimorbidity
Primary: Number of Participants Experiencing Repeat ED Use — 64; 59 Participants
N/A N=670 Improving Coordination and Transitions of Care in Stroke Patients
Stroke · Transient Ischemic Attack
Primary: Stroke Patient Education Retention Tool — 49; 52; 29; 38 Participants
N/A N=19 Transition From Hospital to Home Post Cardiac Condition
Cardiac Condition
Primary: See Primary Outcome Description Below — 8; 3; 8; 3 participants
Phase 3 N=40 Patient Computer Dialog in Primary Care
Patient Computer Dialog
Primary: Patient Post Medical History Assessment Questionnaire — 8.4; 8.3 units on a scale
N/A N=60 Use of the My HealtheVet for Health Information Sharing
Chronic Illness
Primary: Percentage of Participants Who Brought Their VA Information From My HealtheVet to Their Visit With Their Non-VA Provider — 90; 6 Percentage of Participants — p=<0.001