Clinical trial NCT04125433: IT to Support Integration of Social Determinant of Health Services to Reduce Avoidable Emergency Department Visits
Official title: Use of Information Technology to Support Integration of Social Determinant of Health Services to Reduce Avoidable Emergency Department Visits
Study type: INTERVENTIONAL
Overall status: UNKNOWN
Phase: NA
Conditions: Mental Health Issue
Substance Use Disorders
Lead sponsor: Northern New York Rural Behavioral Health Institute
Sponsor class: OTHER
First posted: 2019-10-14
Enrollment: 400
Sex: ALL
Minimum age (years): 18
Maximum age (years): 65
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: NA
Intervention model: SINGLE_GROUP
Intervention model description: In this study a Medicaid Managed Care Plan will identify up to 400 plan members who have visited an emergency department greater than 6 time in a 12-month period. These individuals will receive enhanced integrated peer care services and will be tracked across health and social service venues using a single IT platform. This study will examine the impact of this intervention on total cost of care.
Primary purpose: SUPPORTIVE_CARE

Brief summary: Working through regional Accountable Care Organizations (ACO) the sponsor will establish a 2-year pilot project to demonstrate that early recognition and intervention in the various Social Determinant of Health (SDoH) domains can reduce avoidable Emergency Department (ED) visits by high utilizers. The regional ACO's will contract with Medicaid Managed Care Plans to assign traditional high ED utilizing members to the pilot project. Members will be offered enhanced peer facilitated care management services connecting members with available SDoH community based services. Members fitting our eligibility criteria will self-select by way of completing a pilot project consent form.

Detailed description: The project employs a two level intervention to include Peer Support Specialist (PSS) and Community Health Advocate (CHA). Contact and engagement with participating members will be through both direct intervention in the emergency department by Peer Support Specialist (the peer) as well as in the community for prevention visits and follow up by both the peer and Community Health Advocate. These well-positioned Peers and Community Health Advocates will address Behavioral and Social Determinants of Health (SDoH) concerns through a highly coordinated intervention supported by a common IT Medicaid member tracking platform. This research project will determine the feasibility of deploying a single shared IT platform that will include referral, appointment completion, and intervention outcome data. Project staff will develop a trusting relationship with the members and will improve member access and engagement with community-based services. The project will also seek to determine the impact on total cost of care through redirecting study participants to community resources that are more appropriate, and less expensive than return visits to the emergency department.

Eligibility criteria: Inclusion Criteria:

* Adults age 18 to 65
* New York State Medicaid Managed Care Members
* Have utilized emergency department services 6 or more times in a 12-month period
* Have been assigned to the Pilot Project by their Medicaid Managed Care Plan

Exclusion Criteria:

* Individuals not assigned by a Managed Care Organization meeting the above criteria

Primary outcomes:
measure: Change in Adoption and Use of IT Platform
timeFrame: Months 6, 12, 18, 24
measure: Change in Engagement of Medicaid Member Participants with Peer Integration Care Services
timeFrame: Months 0, 3, 6, 9, 12, 15, 18, 21, 24
measure: Change in Total Cost of Care for Participating Members
timeFrame: Month 0, Month 24
Secondary outcomes:
measure: Change in Emergency Room Visits by Participating Members
timeFrame: Month 0, 6, 12,18,24
Other outcomes:
Locations:
city: Saranac Lake
country: United States
facility: Northern New York Rural Behavioral Health Institute
state: New York
Study officials:
affiliation: Northern NY Rural Behavioral Health Institute
name: Robert Cawley, BBA
role: PRINCIPAL_INVESTIGATOR
References: