Status:
UNKNOWN
Intensive Management of At-risk Patients
Lead Sponsor:
CareMore Health, San Bernardino
Conditions:
Chronic Disease
Eligibility:
All Genders
Phase:
NA
Brief Summary
The purpose of this study is to assess if intensive management of at-risk participants, utilizing longitudinal patient tracking, proactive outreach, multidisciplinary action planning and careful outco...
Detailed Description
At-risk participants will be randomized 1:1 to either usual care or intensive management utilizing longitudinal patient tracking, proactive outreach, multidisciplinary action planning and careful outc...
Eligibility Criteria
Inclusion
- At-risk patients, meaning Gold, Silver, or Bronze tier, as identified by our member 360 platform:
- Gold tier - 6+ emergency department (ED) visits last year, annual spend \>$100,000, 8 or more hierarchical condition category (HCC) diagnoses, readmission \<30 days prior, or ambulatory care-sensitive condition (ACSC) hospitalization \<30 days prior
- Silver tier - 4+ ED visits last year, annual spend \>$75,000, 6 or more HCC diagnoses, readmission \<90 days prior, substance abuse HCC diagnosis, behavioral health admit \<90 days, 15+ chronic medications prescribed in the last 90 days (and not qualifying for Gold tier)
- Bronze tier - 3+ ED visits last year, annual spend \>$50,000, 5 or more HCC diagnoses, 3+ hospitalizations last year, end-stage liver disease, end-stage renal disease, Medicare and Medicaid dual-enrolled, disease-management program patients with ACSC admission or ED visit in the last year, 10+ chronic medications in the last 90 days, 6+ health risk-assessment score, 12+ Edmonton Frail Scale score (and not qualifying for Gold or Silver tiers)
Exclusion
- enrolled in hospice
- enrolled in Institutional Special Needs Plan
- primary patient of study investigator
Key Trial Info
Start Date :
July 1 2020
Trial Type :
INTERVENTIONAL
Allocation :
ESTIMATED
End Date :
December 31 2020
Estimated Enrollment :
600 Patients enrolled
Trial Details
Trial ID
NCT04456725
Start Date
July 1 2020
End Date
December 31 2020
Last Update
July 2 2020
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