Health Care Hotspotting: A Randomized Controlled Trial
Condition: High Utilizers of Hospital Care
Study type: Interventional

Summary: 
      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.
    

Detailed description: 
      The Camden Coalition of Healthcare Providers' Care Management Program, Link2Care, targets
      "super-utilizers" of the health care system. These are individuals with medically and
      socially complex needs who have frequent hospital admissions. Specifically, the Link2Care
      program targets patients in specific Camden hospitals who have had at least two hospital
      admissions in the last six months and have at least two chronic conditions.

      Such heavy utilizers of hospital care account for a disproportionate share of healthcare
      spending. For example, CCHP analyzed hospital admission and emergency department use at three
      Camden hospital systems from 2002-2007 and found that 20% of patients accounted for 90% of
      the costs (Green et al., 2010). As described below, when we compare patients admitted to
      Camden hospitals, in the year prior to an admission, a typical patient targeted by the
      program has 2.5 times more admissions in the prior six months due to the targeting. They are
      also much more likely to be readmitted to the hospital over the year following the hospital
      stay, accruing $73,000 in hospital charges over that time compared to $6600 for other
      patients.

      Link2Care provides intensive care management and coordination for up to 6 months following
      hospital discharge. From October 2012 to January 2014, the median length of the intervention
      for those who completed it was 85 days.

      The approach aims to improve the self-sufficiency of patients in navigating the healthcare
      and social-service systems. It has the potential to reduce healthcare costs and improve
      patient health, as patients learn to use primary care to prevent an escalation of symptoms
      that leads to rehospitalization.

      Participants are assigned to a multidisciplinary care team comprised of a registered nurse,
      licensed practical nurse, social worker, intervention specialist, community health worker,
      and health coaches. A representative from the care team engages with the patient at bedside
      during the hospital admission and plans for the immediate period following discharge.
      Link2Care, as a whole, involves a series of home visits, scheduling of and accompaniment to
      initial primary care and specialty care visits, and support for individuals as they navigate
      various social service agencies to enroll in public programs including TANF, SNAP, and
      programs that promote housing stability.

      The patient is enrolled in the program while still in the hospital. Upon discharge, the care
      team works to visit the patient at home within 3 days of discharge. The care team also works
      to schedule a primary care visit within 7 days of discharge, and appropriate specialist
      visits as necessary At the initial home visit, the care team (1) performs medication
      reconciliation-an inventory of the medications prescribed to gauge appropriateness and
      patient understanding, (2) conducts an assessment of the patient's perception of the
      discharge experience and care coordination, medical/health needs, activity/mobility, service
      needs, and stage of readiness to change, and (3) collaboratively sets goals with the
      individual, such as compliance with the discharge plan. The care team then works closely with
      the patient to achieve these goals; as is needed, the team assists the patient in scheduling
      necessary physician visits, accompanies the patient to those visits, completes applications
      for social services, and coaches the patient in self-care. Subsequent home visits evaluate
      the patient's and the team's progress. The end of the intervention is determined based on
      hospital utilization, individual factors (health education/literacy, disease self-management,
      skills development, level of engagement, self-efficacy) and some systemic factors (access to,
      and the quality of, care, social support, etc.). The person receives a graduation
      certificate. The person is expected to meet their healthcare needs in the future through
      their primary care physician.

      In an earlier, non-randomized evaluation, this program has been found to improve health
      outcomes, decrease utilization of emergency and inpatient services, and decrease costs for a
      cohort of 36 "high utilizers" from $1.2 million monthly to $534,000 monthly, a savings of 56%
      over five years (Green et al., 2010).

      Due to staff and financial constraints, Link2Care is currently administered for only a subset
      of the patients who meet the eligibility criteria, and the patients who are currently
      approached are chosen in an ad-hoc manner. This study would establish a formal process for
      determining - via random assignment - which subset of eligible individuals are offered the
      intervention. This random assignment, which will not reduce the number of individuals who
      benefit from the services, will allow us to isolate the causal effects of the CCHP Link2Care
      Program.
    

Intervention name(s): Link2Care
Intervention type(s): Other
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Supportive Care