Transforming Outcomes for Patients Through Medical Home Evaluation & reDesign

Summary

The purpose of this study is to support enhancement, implementation, and evaluation of an improved model for delivering improved primary care to high-risk older adults through the use of health IT tools, focusing on issues related to the patient-centered primary care home (PCPCH) and other similar high-value elements that are proposed to improve patient outcomes. During this study, participating clinics will utilize the already-implemented Integrated Care Coordination Information System (ICCIS). Clinic staff will meet with a practice facilitator (monthly and as needed), and will track study activities and submit invoices via ICCIS reporting. These invoices will be used to simulate a shared savings model where clinics will be reimbursed based on their progress and effort towards their goals.

Clinics will set and work towards goals that they have chosen. Goals for the control arm are self-selected by the clinics themselves; goals for the invention arm are related to high-value elements (HVE) that have been identified as areas that can improve patient outcomes. These HVE are:

1. Evidence-based Care Management Based on Need
2. Identification of At-Risk Populations
3. Patient Engagement and Alerts Based on Goals
4. Integrated Information for Care Management, especially around Utilization
5. Population Management Tools

Conditions

• Nurse Based Care Management
• Health Information Technology

Interventions

OTHER

Intervention

Will receive payments based on achievement in meeting goals based on specified high value elements as well as effort.

OTHER

Control

Will receive payments based on achievement in meeting goals.

Sponsors & Collaborators

• Gordon and Betty Moore Foundation

  collaborator OTHER

• Care Management Plus

  lead OTHER

Principal Investigators

• David A Dorr, MD, MS · Oregon Health and Science University

• Marsha Pierre-Jacques Williams, BA · Oregon Health and Science University

• Kimberley Gray, BSN · Oregon Health and Science University

Study Design

Allocation

RANDOMIZED

Purpose

SUPPORTIVE_CARE

Masking

SINGLE

Model

PARALLEL

Eligibility

Min Age

18 Years

Sex

ALL

Healthy Volunteers

No

Timeline & Regulatory

Start

2011-07-31

Primary Completion

2014-06-30

Completion

2015-02-28

Countries

• United States

Study Locations