Evaluation of a Personalized Care Management Program for High Hospital Utilizers

Effect of a Personalized Care Management Program on Hospital Inpatient Stays Among High Utilizers: A Randomized Clinical Trial

This randomized clinical trial intends to evaluate the effectiveness of enrollment in Atrium Health's Multiple Visit Patient (MVP) care management program compared to usual care on reducing 12-month total inpatient hospital utilization among patients with high past volume of hospital inpatient stays.

Study Overview

• Status: Completed
• Conditions: Comorbidities and Coexisting Conditions

Detailed Description

The list of patients with four or more inpatient hospital visits in 2019 will be pulled from the Atrium Health electronic data warehouse (EDW) by IAS Clinical Quality Analytics, and eligibility for the MVP program of patients on this list will be determined by the Population Health's Care Management team based on predefined eligibility criteria. IAS CORE will randomize eligible participants into one of two groups: 1) MVP program; or 2) usual care.

Population Health's Multiple Visit Patient (MVP) care management program aims to manage health and lower hospital utilization among patients with a history of high inpatient hospital stays at Atrium Health. Patients eligible for the program have four or more inpatient visits over the 12-month period prior to enrollment. Once enrolled, each MVP program participant receives on-going support from an assigned MVP care manager and larger care management team, including the following core program components:

1. customized care plan developed for each patient at the time of enrollment
2. routine, virtual health monitoring and collaborative care management team-based review
3. personalized navigation and coordination across multidisciplinary Atrium Health services, as needed
4. education, health coaching, and support via telephonic and in-person interactions, as needed

The control group will receive usual care.

Upon completion of the 12-month period during which outcomes data will be accrued, the study will evaluate whether 12-month participation in the MVP program care management program, compared to usual care, reduced inpatient hospital use.

• Study Type: Observational
• Enrollment (Actual): 454

Contacts and Locations

Study Locations

• United States
  • North Carolina
    • Charlotte, North Carolina, United States, 28203
      • Atrium Health - Care Management Program

Participation Criteria

Eligibility Criteria

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

• Sampling Method: Non-Probability Sample

Study Population

Patients included in the evaluable population for this project, will have their data inform the final outcomes assessment. All patients who meet the inclusion and exclusion criteria in both groups will be assessed for the primary outcome (intent to treat).

Description

Inclusion Criteria:

• 18 years of age or older
• 4 or more inpatient hospital visits across Atrium Health Metro hospitals in 2019

Exclusion Criteria:

• Existing MVP participants
• Patients who at the time of identification for the MVP program are:
• Actively enrolled in a Levine Cancer Institute oncology navigation program
• Actively receiving hospice or palliative care
• Attributed to a primary care provider at an outside healthcare system
• Patients whose primary residence is a skilled nursing facility

Study Plan

How is the study designed?

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort
Multiple Visit Patient (MVP) Program; The MVP program aims to manage health and lower hospital utilization among patients with a history of high inpatient hospital stays at Atrium Health. Patients eligible for the program have four or more inpatient visits over the 12-month period prior to enrollment. Once enrolled, each MVP program participant receives on-going support from an assigned MVP care manager and larger care management team, including the following core program components: customized care plan developed for each patient at the time of enrollment routine, virtual health monitoring and collaborative care management team-based review personalized navigation and coordination across multidisciplinary Atrium Health services, as needed. Education, health coaching, and support via telephonic and in-person interactions, as needed.
Usual Care; Atrium Health standard of care. Patient's post-discharge usual care depends on the inpatient care management assessment at last hospital admission. Patients can be discharged to home and receive no further care, or home with home health, or to a skilled nursing facility (SNF) or another type of Continuing Care facility. Patients can be referred to advanced illness management, hospice, and Community Care Partners by the inpatient care manager. Patient can be referred to Ambulatory Care Management for care management also via telehealth, by a primary care physician or the Transitions Clinic.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of inpatient (IP) hospital encounters over a 12 month period	Inpatient encounter is defined as an admission to an Atrium Health acute care hospital	12 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of inpatient hospital encounters over a 6 month period	Inpatient encounter is defined as an admission to an Atrium Health acute care hospital	6 months
Combined Inpatient and Observational hospital encounters - Atrium only	Combined number of IP and OBS encounters at Atrium Health hospitals	6 months
Combined Inpatient and Observational hospital encounters - non-Atrium included	Combined number of IP and OBS encounters at Atrium Health and non-Atrium Health hospitals	6 months
Combined Inpatient and Observational hospital encounters - Atrium only	Combined number of IP and OBS encounters at Atrium Health hospitals	12 month
Combined Inpatient and Observational hospital encounters - non-Atrium included	Combined number of IP and OBS encounters at Atrium Health and non-Atrium Health hospitals	12 month
Inpatient Readmission	Among patients with at least 1 encounter during the study period, 30-day all cause non-elective inpatient readmission rate to any AH hospital	6 month
Inpatient Readmission	Among patients with at least 1 encounter during the study period, 30-day all cause non-elective inpatient readmission rate to any AH hospital	12 month
Inpatient Readmission - Same Hospital	Among patients with at least 1 encounter during the study period, 30-day all cause non-elective inpatient readmission rate to the same AH hospital as the index encounter	6 month
Inpatient Readmission - Same Hospital	Among patients with at least 1 encounter during the study period, 30-day all cause non-elective inpatient readmission rate to the same AH hospital as the index encounter	12 month
Emergency Department Encounters	Number of patient emergency department encounters	6 month
Emergency Department Encounters	Number of patient emergency department encounters	12 month
Mortality	Dichotomous indicator of all-cause mortality within 6 months from the beginning of the study period	6 month
Mortality	Dichotomous indicator of all-cause mortality within 12 months from the beginning of the study period	12 month
Hospital Bed Days (Inpatient)	Total length of stay (LOS) in days (discharge date to admissions date) for acute care IP utilization	6 month
Hospital Bed Days (Inpatient)	Total length of stay (LOS) in days (discharge date to admissions date) for acute care IP utilization	12 month
Hospital Charges	Total accrued hospital billed charges for inpatient encounter at Atrium Health primary enterprise acute care facilities.	6 month
Hospital Charges	Total accrued hospital billed charges for inpatient encounter at Atrium Health primary enterprise acute care facilities.	12 month

Collaborators and Investigators

• Sponsor: Wake Forest University Health Sciences
• Investigators: Principal Investigator: Alica Sparling, PhD, Wake Forest University Health Sciences

Study record dates

Study Major Dates

• Study Start (Actual): April 23, 2020
• Primary Completion (Actual): May 1, 2021
• Study Completion (Actual): August 31, 2021

Study Registration Dates

• First Submitted: January 12, 2021
• First Submitted That Met QC Criteria: January 26, 2021
• First Posted (Actual): January 27, 2021

Study Record Updates

• Last Update Posted (Actual): April 22, 2022
• Last Update Submitted That Met QC Criteria: April 14, 2022
• Last Verified: September 1, 2021

More Information

Terms related to this study

• Keywords: Patient Care Management; Patient Hospital Admissions
• Other Study ID Numbers: IRB00082498; 04-20-10E (Other Identifier: Atrium)

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