Health Care Hotspotting: A Randomized Controlled Trial
Completed · Not applicable
Conditions studied: High Utilizers of Hospital Care
In brief
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.
Key facts
- Study ID
- NCT02090426
- Run by
- Abdul Latif Jameel Poverty Action Lab
- People needed
- 800
- Starts
- 2014-06-02
- Expected to finish
- 2020-01-01
- Last updated by the study team
- 2020-11-19
Who can join
Age: 19 and older, up to 80. Sex: any. Healthy volunteers: not accepted.
You may qualify if…
- 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
You may not qualify if…
- 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
Where it is running
- Cooper University Hospital — Camden, New Jersey, United States
- Our Lady of Lourdes Medical Center — Camden, New Jersey, United States
Full record on ClinicalTrials.gov
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