Health Care Hotspotting: A Randomized Controlled Trial

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.

Study Overview

• Status: Completed
• Conditions: High Utilizers of Hospital Care
• Intervention / Treatment: Other: Link2Care

Detailed Description

The Camden Coalition of Healthcare Providers' Care Management Program, Link2Care, targets "super-utilizers" of the health care system. These are individuals with medically and socially complex needs who have frequent hospital admissions. Specifically, the Link2Care program targets patients in specific Camden hospitals who have had at least two hospital admissions in the last six months and have at least two chronic conditions.

Such heavy utilizers of hospital care account for a disproportionate share of healthcare spending. For example, CCHP analyzed hospital admission and emergency department use at three Camden hospital systems from 2002-2007 and found that 20% of patients accounted for 90% of the costs (Green et al., 2010). As described below, when we compare patients admitted to Camden hospitals, in the year prior to an admission, a typical patient targeted by the program has 2.5 times more admissions in the prior six months due to the targeting. They are also much more likely to be readmitted to the hospital over the year following the hospital stay, accruing $73,000 in hospital charges over that time compared to $6600 for other patients.

Link2Care provides intensive care management and coordination for up to 6 months following hospital discharge. From October 2012 to January 2014, the median length of the intervention for those who completed it was 85 days.

The approach aims to improve the self-sufficiency of patients in navigating the healthcare and social-service systems. It has the potential to reduce healthcare costs and improve patient health, as patients learn to use primary care to prevent an escalation of symptoms that leads to rehospitalization.

Participants are assigned to a multidisciplinary care team comprised of a registered nurse, licensed practical nurse, social worker, intervention specialist, community health worker, and health coaches. A representative from the care team engages with the patient at bedside during the hospital admission and plans for the immediate period following discharge. Link2Care, as a whole, involves a series of home visits, scheduling of and accompaniment to initial primary care and specialty care visits, and support for individuals as they navigate various social service agencies to enroll in public programs including TANF, SNAP, and programs that promote housing stability.

The patient is enrolled in the program while still in the hospital. Upon discharge, the care team works to visit the patient at home within 3 days of discharge. The care team also works to schedule a primary care visit within 7 days of discharge, and appropriate specialist visits as necessary At the initial home visit, the care team (1) performs medication reconciliation-an inventory of the medications prescribed to gauge appropriateness and patient understanding, (2) conducts an assessment of the patient's perception of the discharge experience and care coordination, medical/health needs, activity/mobility, service needs, and stage of readiness to change, and (3) collaboratively sets goals with the individual, such as compliance with the discharge plan. The care team then works closely with the patient to achieve these goals; as is needed, the team assists the patient in scheduling necessary physician visits, accompanies the patient to those visits, completes applications for social services, and coaches the patient in self-care. Subsequent home visits evaluate the patient's and the team's progress. The end of the intervention is determined based on hospital utilization, individual factors (health education/literacy, disease self-management, skills development, level of engagement, self-efficacy) and some systemic factors (access to, and the quality of, care, social support, etc.). The person receives a graduation certificate. The person is expected to meet their healthcare needs in the future through their primary care physician.

In an earlier, non-randomized evaluation, this program has been found to improve health outcomes, decrease utilization of emergency and inpatient services, and decrease costs for a cohort of 36 "high utilizers" from $1.2 million monthly to $534,000 monthly, a savings of 56% over five years (Green et al., 2010).

Due to staff and financial constraints, Link2Care is currently administered for only a subset of the patients who meet the eligibility criteria, and the patients who are currently approached are chosen in an ad-hoc manner. This study would establish a formal process for determining - via random assignment - which subset of eligible individuals are offered the intervention. This random assignment, which will not reduce the number of individuals who benefit from the services, will allow us to isolate the causal effects of the CCHP Link2Care Program.

• Study Type: Interventional
• Enrollment (Actual): 800
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • New Jersey
    • Camden, New Jersey, United States, 08103
      • Cooper University Hospital
    • Camden, New Jersey, United States, 08103
      • Our Lady of Lourdes Medical Center

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 19 years to 80 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

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

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Supportive Care
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
No Intervention: Standard Care; Individuals in the standard care arm receive standard discharge planning from the hospital with no followup by Link2Care team members.
Experimental: Link2Care; Participants are assigned to a multidisciplinary care team (Link2Care) comprised of a registered nurse, licensed practical nurse, social worker, intervention specialist, community health worker, and health coaches. A representative from the care team engages with the patient at bedside during the hospital admission and plans for the immediate period following discharge. The Program, as a whole, involves a series of home visits, scheduling of and accompaniment to initial primary care and specialty care visits, and support for individuals as they navigate various social service agencies to enroll in public programs including TANF, SNAP, and programs that promote housing stability.	Other: Link2Care

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
Any Hospital Readmission	180-day from indexed hospital discharge

Secondary Outcome Measures

Outcome Measure	Time Frame
Any Emergency Department Use	180-day from indexed hospital discharge
Any Hospital Use (Inpatient or ED)	180-day from indexed hospital discharge
Inpatient Readmission From the ED	180-day from indexed hospital discharge
Inpatient Readmission Not From the ED	180-day from indexed hospital discharge
Number of Readmissions	180-day from indexed hospital discharge
Had 2+ Readmissions	180-day from indexed hospital discharge
Number of Days in the Hospital	180-day from indexed hospital discharge
Hospital Charges	180-day from indexed hospital discharge
Hospital Receipts	180-day from indexed hospital discharge

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of Readmissions		30-day from indexed hospital discharge
Number of Readmissions		90-day from indexed hospital discharge
Number of Readmissions	Outcome is the number of hospital readmissions within 365-days from index hospital discharge and is reported for the subset of participants for which sufficient time has passed that 365-day outcomes can be observed in hospital claims data.	365-day from indexed hospital discharge
Any Hospital Use (Inpatient or ED)		365-day from indexed hospital discharge
Time to Readmission (Days)	Outcome is the number of days until readmission for the subset of participants for which sufficient time has passed that 365-day outcomes can be observed in hospital claims data and who had a readmission within 365 days.	Up to 365 days from indexed hospital discharge
Number of Readmissions (for Patients With 3+ Readmissions in the Prior Year)		180-day from indexed hospital discharge
Number of Readmissions (for Patients With 2 Readmissions in the Prior Year)		180-day from indexed hospital discharge
Number of Readmissions (for English Speaking Patients)		180-day from indexed hospital discharge
Number of Readmissions (for Non-English Speaking Patients)		180-day from indexed hospital discharge

Collaborators and Investigators

• Sponsor: Abdul Latif Jameel Poverty Action Lab
• Collaborators: Massachusetts Institute of Technology; Harvard University; The Cooper Health System; National Bureau of Economic Research, Inc.
• Investigators: Principal Investigator: Amy N Finkelstein, PhD, The Abdul Latif Jameel Poverty Action Lab/MIT; Principal Investigator: Jeffery Brenner, MD, The Cooper Health System

Publications and helpful links

General Publications

• Finkelstein A, Zhou A, Taubman S, Doyle J. Health Care Hotspotting - A Randomized, Controlled Trial. N Engl J Med. 2020 Jan 9;382(2):152-162. doi: 10.1056/NEJMsa1906848.

Study record dates

Study Major Dates

• Study Start (Actual): June 2, 2014
• Primary Completion (Actual): October 1, 2018
• Study Completion (Actual): January 1, 2020

Study Registration Dates

• First Submitted: March 17, 2014
• First Submitted That Met QC Criteria: March 17, 2014
• First Posted (Estimate): March 18, 2014

Study Record Updates

• Last Update Posted (Actual): November 19, 2020
• Last Update Submitted That Met QC Criteria: October 27, 2020
• Last Verified: October 1, 2020

More Information

Terms related to this study

• Other Study ID Numbers: JPAL-763