Transforming Outcomes for Patients Through Medical Home Evaluation & reDesign

Study Overview
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Brief Summary
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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: Evidence-based Care Management Based on Need Identification of At-Risk Populations Patient Engagement and Alerts Based on Goals Integrated Information for Care Management, especially around Utilization Population Management Tools

Official Title
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Transforming Outcomes for Patients Through Medical Home Evaluation & reDesign

Conditions
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Nurse Based Care Management, Health Information Technology

Intervention / Treatment
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* Other: Intervention
* Other: Control


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: clinics must be from the Oregon Rural Practice-based Research Network (ORPRN) Primary care clinic meeting one of the following health care setting descriptions: 1) small clinics in rural area, 2) medium-sized clinics in rural area, 3) clinics in moderate-sized health system, or 4) clinic within an academic medical center; Clinic will or has attested for PCPCH, achieving Tier 2 or 3 (of 3 tiers); Clinic is willing to contract to be a PCPCH with payers; Clinic has stable electronic health record (EHR) system with no plans to change systems during study duration; Clinic has willingness to receive practice facilitation and participate in study activities, including completion of assessments; Clinic has willingness to engage with research team members as defined in the study. Exclusion Criteria: patients less then 18

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Supportive Care
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Intervention<br>Financial incentives will be provided based on performance in areas determined to be of high-value. | Other: Intervention<br>* Will receive payments based on achievement in meeting goals based on specified high value elements as well as effort.<br>|
| Active Comparator: Control<br>Financial incentives are a flat rate which can be reduced if an appropriate amount of effort or improvement is not met | Other: Control<br>* Will receive payments based on achievement in meeting goals.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Preventable utilization | Reduce by 15% ED visits and hospitalizations related to ambulatory care | 12 months | 
| Quality Measures Improvement | Select 3 standard measures related to the patient population and improve each by 20%. (An example of such a measure might be fall risk assessment. There are several quality measures that are included as part of the HIT tool that is provided to clinics.) | 12 months | 
| Patient Satisfaction | Improve patient experience with clinic and satisfaction with care coordination by 10% Patient satisfaction will be determined by a CAHPS patient satisfaction survey that is sent out at the start and end of the study. | 12 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Care coordination, nurse care management, practice facilitation, health information technology