IT to Support Integration of Social Determinant of Health Services to Reduce Avoidable Emergency Department Visits

Use of Information Technology to Support Integration of Social Determinant of Health Services to Reduce Avoidable Emergency Department Visits

Working through regional Accountable Care Organizations (ACO) the sponsor will establish a 2-year pilot project to demonstrate that early recognition and intervention in the various Social Determinant of Health (SDoH) domains can reduce avoidable Emergency Department (ED) visits by high utilizers. The regional ACO's will contract with Medicaid Managed Care Plans to assign traditional high ED utilizing members to the pilot project. Members will be offered enhanced peer facilitated care management services connecting members with available SDoH community based services. Members fitting our eligibility criteria will self-select by way of completing a pilot project consent form.

Study Overview

• Status: Unknown
• Conditions: Substance Use Disorders; Mental Health Issue
• Intervention / Treatment: Behavioral: Peer Integrated Care Services

Detailed Description

The project employs a two level intervention to include Peer Support Specialist (PSS) and Community Health Advocate (CHA). Contact and engagement with participating members will be through both direct intervention in the emergency department by Peer Support Specialist (the peer) as well as in the community for prevention visits and follow up by both the peer and Community Health Advocate. These well-positioned Peers and Community Health Advocates will address Behavioral and Social Determinants of Health (SDoH) concerns through a highly coordinated intervention supported by a common IT Medicaid member tracking platform. This research project will determine the feasibility of deploying a single shared IT platform that will include referral, appointment completion, and intervention outcome data. Project staff will develop a trusting relationship with the members and will improve member access and engagement with community-based services. The project will also seek to determine the impact on total cost of care through redirecting study participants to community resources that are more appropriate, and less expensive than return visits to the emergency department.

• Study Type: Interventional
• Enrollment (Anticipated): 400
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Barry Brogan, MAPP; Phone Number: 518-891-9460; Email: barry@behaviorhealthnet.orh
• Study Contact Backup: Name: Robert Cawley, BBA; Phone Number: 518-891-9460; Email: robert@behaviorhealthnet.org

Study Locations

• United States
  • New York
    • Saranac Lake, New York, United States, 12983
      • Northern New York Rural Behavioral Health Institute
      • Contact: Robert Cawley, BBA; Phone Number: 518-891-9460; Email: robert@behaviorhealthnet.org
      • Contact: Barry Brogan, MAPP; Phone Number: 518-891-9460; Email: barry@behaviorhealthnet.org

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 65 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Adults age 18 to 65
• New York State Medicaid Managed Care Members
• Have utilized emergency department services 6 or more times in a 12-month period
• Have been assigned to the Pilot Project by their Medicaid Managed Care Plan

Exclusion Criteria:

• Individuals not assigned by a Managed Care Organization meeting the above criteria

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Supportive Care
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm

Intervention / Treatment

Experimental: Medicaid Emergency Department High Utilizers; This Arm will include the following individuals; Up to 400 Adults age 18 to 65; New York State Medicaid Managed Care Members; Have utilized emergency department services 6 or more times in a 12-month period; Have been assigned to the Pilot Project by their Medicaid Managed Care Plan

Behavioral: Peer Integrated Care Services; The project employs a two level intervention to include Peer Support Specialist (PSS) and Community Health Advocate (CHA). Contact and engagement with participating members will be through both direct intervention in the emergency department as well as in the community for prevention visits and follow up. Peers and Community Health Advocates will address Behavioral and Social Determinants of Health (SDoH) concerns through a coordinated intervention supported by a common IT Medicaid member tracking platform. This research project will determine the feasibility of deploying a single shared IT platform that will include referral, appointment completion, and intervention outcome data. Project staff will develop a relationship with the members improving member access and engagement with community-based services. The project will determine the impact on total cost of care through redirecting study participants to community resources rather than return visits to the emergency department.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Adoption and Use of IT Platform	Change in Number of Participating Agencies That Contribute Data to the IT System	Months 6, 12, 18, 24
Change in Engagement of Medicaid Member Participants with Peer Integration Care Services	The change in acceptance by Medicaid Members of Peer Integrated Care Services	Months 0, 3, 6, 9, 12, 15, 18, 21, 24
Change in Total Cost of Care for Participating Members	Change in cost trend for participating members. Pre-study vs. study period.	Month 0, Month 24

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Emergency Room Visits by Participating Members	Change in rate of Emergency Department utilization by participating members.	Month 0, 6, 12,18,24

Collaborators and Investigators

• Sponsor: Northern New York Rural Behavioral Health Institute
• Investigators: Principal Investigator: Robert Cawley, BBA, Northern NY Rural Behavioral Health Institute

Study record dates

Study Major Dates

• Study Start (Anticipated): August 1, 2020
• Primary Completion (Anticipated): June 30, 2022
• Study Completion (Anticipated): August 30, 2022

Study Registration Dates

• First Submitted: October 10, 2019
• First Submitted That Met QC Criteria: October 11, 2019
• First Posted (Actual): October 14, 2019

Study Record Updates

• Last Update Posted (Actual): October 14, 2019
• Last Update Submitted That Met QC Criteria: October 11, 2019
• Last Verified: October 1, 2019

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Mental Disorders; Chemically-Induced Disorders; Pathologic Processes; Disease Attributes; Substance-Related Disorders; Emergencies
• Other Study ID Numbers: NCBHNPIC

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No