Integrated Care (IC) Models for Patient-Centered Outcomes

Summary

Multiple chronic conditions (MCC) are widely recognized as the U.S. public health challenge of the 21st century. These physical and behavioral health conditions take a large toll on those living with chronic diseases, including many who are publicly insured, as well as caregivers and society. While evidence-based integrated care models can improve outcomes for individuals with MCC, such models have not yet been widely implemented. Insurance providers/payers have innovative system features that can be used to deploy these models; however, the investigators do not yet know which of these features can best help to improve outcomes for individuals with MCC in general or high-need subgroups in particular. As a result, patients lack information to make important decisions about their health and health care, and system-level decision makers face ongoing challenges in effectively and efficiently supporting those with MCC.

This real-world study will provide useful information about available options for supporting individuals with MCC. Building on existing integrated care efforts, the investigators will enroll N=1,400 (a modified total N) adults with MCC at risk for repeated hospitalizations and assess the impact of three payer-led options (e.g. High-Touch, High-Tech, Standard Care/Optimal Discharge Planning (ODP)) on patient-centered outcomes, namely patient activation in health care, health status, and subsequent re-hospitalization. The investigators will also determine which option works best for whom under what circumstances by gathering information directly from individuals with MCC through self-report questionnaires, health care use data, and interviews.

Conditions

• Diabetes
• Asthma
• Chronic Obstructive Pulmonary Disease
• Hypertension
• Anxiety
• Atrial Fibrillation
• Congestive Heart Failure
• Depression
• Bipolar Disorder
• Schizophrenia

Interventions

BEHAVIORAL

High-Touch

Intensive, in-person and/or telephonic support.

BEHAVIORAL

High-Tech

Remote care management and self-directed digital tools.

BEHAVIORAL

Optimal Discharge Planning

Transition to other Health Plan disease management programs and/or community resources.

Sponsors & Collaborators

• Patient-Centered Outcomes Research Institute

  collaborator OTHER

• University of Pittsburgh

  lead OTHER

Principal Investigators

• Dan Swayze, DrPH, MBA · University of Pittsburgh

Study Design

Allocation

RANDOMIZED

Purpose

HEALTH_SERVICES_RESEARCH

Masking

NONE

Model

FACTORIAL

Eligibility

Min Age

21 Years

Sex

ALL

Healthy Volunteers

Yes

Timeline & Regulatory

Start

2018-09-04

Primary Completion

2022-11-30

Completion

2022-11-30

Countries

• United States

Study Locations