Comparing Three Care Models for Medicare Patients at Risk of Hospitalization Care Coordination Team, Comprehensive Care Physician, and Community & Culture Program

What this Trial Is About

Researchers are evaluating different care programs to reduce hospitalizations among socioeconomically disadvantaged Medicare patients who are at higher risk of being hospitalized. The study compares three care models Ambulatory Care Coordination Team ACCT, Comprehensive Care Physician CCP program, and the Comprehensive Care, Community and Culture Program C4P. The goal is to understand how these programs impact hospital stays, patient involvement, satisfaction, health status, and goal achievement over one year. The study involves randomly assigning 3,000 patients into three groups of 1,000 each. In the ACCT group, patients receive care from different doctors in hospital and clinic, with access to nurse and social worker care coordination services for high-risk patients. The CCP group receives care from the same physician for both inpatient and outpatient needs to enhance continuity. The C4P group builds upon the CCP model by adding screening for unmet social needs, community health worker support, and access to community-based arts and culture programs to better engage patients. Participants will be involved for up to 4.5 years, with key assessments including hospitalization rates tracked quarterly via Medicare claims. Researchers will also measure patient activation, satisfaction with care, general and mental health status, and personal goal attainment using surveys and health assessments. The study aims to identify which care approach best supports patients in reducing hospitalizations and improving overall health and engagement.

Comprehensive Care Community and Culture Study