Ambulatory ICU Study for Medically and Socially Complex Patients
Condition: Health Services; Comorbidity; Primary Health Care
Study type: Interventional

Summary: 
      This is a prospective randomized wait-list control study to determine whether a stand-alone,
      co-located team of physician, mental health behaviorist, and care coordinators with decreased
      panel size (aka "intensive primary care") will reduce inpatient and emergency care
      utilization, inpatient costs of care, and improve patient activation and experience for
      medically and socially complex patients, compared to enhanced usual care at 6 and 12 months.
      Participants with multiple co-morbidities, and meet utilization criteria will have the
      opportunity to enroll; half the participants will start the intervention immediately, while
      half will continue enhanced usual care for 6 months before beginning the intervention.
    

Detailed description: 
      The goal of this study is to conduct an evaluation of an "Ambulatory-ICU" model of primary
      care for "high utilizer" patients with medical, behavioral, and social complexity. A small
      proportion of patients use > 50 % of healthcare resources. It is currently unknown what
      interventions can help reduce inappropriate utilization due to lack of studies with rigorous
      study design, particularly in patients with high rates of homelessness, mental illness and
      substance use. The use of high-risk teams for select patients is a promising model of primary
      care that removes barriers to accessing usual care services by centralizing medical and
      behavioral clinical services, promotes ability to outreach beyond the clinic, and promote
      continuity of care and trust-building between patient and provider teams.

      This study will test the hypothesis that a stand-alone clinic based intervention of a
      multidisciplinary, co-located physician, mental health behaviorist, nursing, pharmacist, and
      care coordinators with reduced panel size, and focus on patient capacity building and
      decreasing treatment burden will improve health outcomes at 6 and 12 months in a low-income
      high utilizer population with history of homelessness.

      Enhanced usual care comprises of care delivered at Old Town Clinic (OTC) a Federally
      Qualified Health Center (FQHC) that is modeled on the Patient Centered Medical Home (PCMH)
      model. Patients have a designated primary care physician and care team with access to chronic
      disease education, mental health, social work, and substance abuse programs through referral
      system. In addition, participants thought to have difficulty engaging in primary care have
      access to a Health Resilience Specialist, a community health worker intervention who conducts
      outreach and assists the patient in care navigation.
    

Intervention name(s): SUMMIT intervention; Enhanced usual care
Intervention type(s): Other; Other
Intervention description(s): See description in experimental arm.; See description in active comparator arm.
Other intervention name(s): intensive primary care team, complex care team; usual care
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: This is a pragmatic "wait-list" control design. Participants will be consented and baseline survey administered after which patient will be randomized by computer generated algorithm into 2 arms: immediate or 6-month 'wait-list.' Immediate group will start intervention and be followed at 6 month intervals for 12 months. 'Wait-list' group will resume usual care for 6-months, after which they will cross-over to the intervention group for 12 months.
Masking: Triple (Participant, Care Provider, Investigator)
Primary purpose: Health Services Research
Keywords: Patient-Centered Care; Comorbidity