Evaluating the Impact of a Supportive Care Program

Study Overview
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Brief Summary
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NYU's High Risk Program targets patients who may be more likely to have increased hospitalization due to health conditions that may cause death in the near future. Community Health Workers, a home visiting doctor service, a supportive care nurse, and behavioral health specialist engage the population to address a range of biopsychosocial needs with end goal in increasing support in the community and engaging palliative and hospice care when appropriate to prevent hospital readmissions, shorten length of stay, reduce hospital utilization, and decrease overall patient cost with a focus on hospital spend.

Official Title
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Evaluating the Impact of a Supportive Care Program

Conditions
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Patient Engagement, Morality

Intervention / Treatment
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* Behavioral: Supportive care program


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: 18 years or older at or above the 75th percentile on the Mortality Model Attributed to a value based contract Exclusion Criteria: Less than 18 years of age Below the 75th percentile on the Mortality Model Not attributed to a value based contract

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| HealthFirst Intervention<br>Patients attributed to HealthFirst who will receive the intervention | Behavioral: Supportive care program<br>* Community Health Workers, a home visiting doctor service, a supportive care nurse, and behavioral health specialist engage the population to address a range of biopsychosocial needs with end goal in increasing support in the community and engaging palliative and hospice care when appropriate to prevent hospital readmissions, shorten length of stay, reduce hospital utilization, and decrease overall patient cost with a focus on hospital spend.<br>|
| HealthFirst Control<br>Patients attributed to HealthFirst who will not receive the intervention | |
| Mortality Model Intervention<br>Patients who are identified as High Risk by the mortality predictive model and who receive the intervention. | Behavioral: Supportive care program<br>* Community Health Workers, a home visiting doctor service, a supportive care nurse, and behavioral health specialist engage the population to address a range of biopsychosocial needs with end goal in increasing support in the community and engaging palliative and hospice care when appropriate to prevent hospital readmissions, shorten length of stay, reduce hospital utilization, and decrease overall patient cost with a focus on hospital spend.<br>|
| Mortality Model Control<br>Patients who are identified as High Risk by the mortality predictive model and who do not receive the intervention. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rate of Advance Care Planning note creation | How many and how often are ACP notes written for patients | 2 years |