Connecting Low-Income Adults to Primary Care After Inpatient Discharge

Healthcare systems and insurers have tried to reduce costs by improving the care and coordination provided to patients with high healthcare spending. Often termed, "hotspotting", these interventions seek to lower costs by reducing care provided in fragmented, high-cost settings, including the emergency department and inpatient settings, by addressing the social determinants of health and improving patients' access to lower-cost, ambulatory settings. Vanderbilt University Medical Center (VUMC), in collaboration with Tennessee's Medicaid agency (TennCare), is piloting a program to reduce costs and improve the quality of care provided to high-risk TennCare enrollees by referring them from inpatient settings to VUMC primary care services. This study seeks to evaluate this pilot by comparing outcomes between Medicaid patients referred to VUMC primary care services and similar Medicaid patients not referred to VUMC primary care services using data from surveys and administrative sources, including electronic health records and health insurance claims.

Study Overview

• Status: Completed
• Conditions: Health Care Utilization; Health Care Seeking Behavior
• Intervention / Treatment: Other: Access to primary care services

• Study Type: Observational
• Enrollment (Actual): 200

Contacts and Locations

Study Locations

• United States
  • Tennessee
    • Nashville, Tennessee, United States, 37232
      • Vanderbilt University Medical Center

Participation Criteria

Eligibility Criteria

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

• Sampling Method: Non-Probability Sample

Study Population

Patients age 18 or older who are currently enrolled in Tennesee's Medicaid program (TennCare) and who are presenting in VUMC's inpatient setting, and who report no active relationship with a primary care doctor.

Description

Inclusion Criteria:

• Age 18 or older
• Currently enrolled in Tennessee's Medicaid Program (TennCare)
• Presenting in VUMC's inpatient setting
• Reporting no active relationship with a primary care doctor
• Lives in Davidson County, Tennessee, or a surrounding county

Exclusion Criteria:

• Patients discharged to a setting other than the community (e.g. to a Skilled Nursing Facility)

Study Plan

How is the study designed?

Design Details

• Observational Models: Other
• Time Perspectives: Prospective

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Pilot Group; This group of TennCare recipients will be referred to VUMC primary care services and will be allowed to utilize these services for at least two years. Those referred to VUMC primary care services will be those who belong to the two of state's three Medicaid Managed Care plans who have agreed to participate in this pilot.	Other: Access to primary care services; Those in the pilot group will be referred to primary care services and allowed to utilize them for at least two years. Primary care services include access to a primary care physician, medical management, and other tasks typically performed by a general practitioner. Those referred to primary care services will not have access to other VUMC outpatient services.
Control Group; This group of TennCare recipients will not be referred to VUMC primary care services and will receive care as usual. Those not referred to VUMC primary care services will be those who belong to one of the state's three Medicaid Managed Care plans who has not agreed to participate in this pilot.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of Inpatient Admissions	How many times the participant is hospitalized within the specified time period	30, 60, 90, 180, and 360 days

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of Emergency Department Visits	How many times the participant presents to the emergency department within the specified time period	30, 60, 90, 180, and 360 days
Number of Primary Care Visits	How many times the participant has seen a primary care physician within the specified time period	30, 60, 90, 180, and 360 days
Average Health Care Spending	Health care expenditures by the patient within the specified time frame	30, 60, 90, 180, and 360 days
Average Self-reported Health Status	A measure of the patient's self-reported physical and mental health, as measured by a shorter, modified version of the Short Form (SF)-36	30, 60, 90, 180, and 360 days
Average of Disease Specific Outcomes	Depending on the clinical information that is captured, disease specific clinical outcomes (e.g. prevalence of hypertension; HbA1C levels) will also be reported	30, 60, 90, 180, and 360 days

Collaborators and Investigators

• Sponsor: Vanderbilt University Medical Center

Study record dates

Study Major Dates

• Study Start (Actual): December 15, 2022
• Primary Completion (Actual): April 1, 2025
• Study Completion (Actual): April 1, 2025

Study Registration Dates

• First Submitted: September 30, 2022
• First Submitted That Met QC Criteria: September 30, 2022
• First Posted (Actual): October 5, 2022

Study Record Updates

• Last Update Posted (Actual): April 29, 2025
• Last Update Submitted That Met QC Criteria: April 28, 2025
• Last Verified: February 1, 2025

More Information

Terms related to this study

• Keywords: Medicaid; Hospitalizations; Health Care Costs; Emergency Department Use; Health Care Accessibility; Low-income populations
• Other Study ID Numbers: 221128

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
• product manufactured in and exported from the U.S.: No