Comprehensive Care Community and Culture Study

Conditions

• Comprehensive Care
• Cost of Care
• Medicare
• Quality of Care

Eligibility Criteria

Sex

ALL

Age

18 Years - N/A

Healthy Volunteers

Not accepted

Interventions

• Ambulatory Care Coordinator Team (ACCT) — BEHAVIORAL
  See arm description
• Comprehensive Care Physician Program (CCP) — BEHAVIORAL
  see arm description
• Comprehensive Care Community & Culture Program (C4P) — BEHAVIORAL
  see arm description

Study Details

This randomized trial is evaluating whether socioeconomically disadvantaged Medicare patients at increased risk of hospitalization experience fewer hospitalization if those patients are offered care in: 1) ACCT, where patients receive care from different physicians in the hospital and the clinic settings and have access to nurse and social worker care coordination services, 2) CCP where patients receive care from one physician in the inpatient and outpatient settings or 3) C4P which adds screening of unmet social needs, community health worker support and arts and culture programming to CCP. The study will determine how these programs affect patient activation and engagement in care, satisfaction with care, general health and mental health, and goal attainment.

Key Dates

Start date

Mar 6, 2019

Status verified

Apr 2025

Primary completion

Jul 31, 2027

Completion

Jul 31, 2029

Study Design

Enrollment

3,000 participants (estimated)

Allocation

RANDOMIZED

Intervention model

PARALLEL

Primary purpose

HEALTH_SERVICES_RESEARCH

Arms

• Active Comparator: Ambulatory Care Coordinator Team (ACCT)
  Patients randomized to ACCT receive care from different doctors in clinic and in the hospital. ACCT patients who have been hospitalized twice, had 4 emergency department (ED) visits in the last year or are referred by their primary care physician are offered ACCT care coordination services (ACCT-CC) from nurses and social workers who manage their care with the larger clinical team. Patients are graduated from ACCT if the ACCT team thinks they are no longer high risk.
• Active Comparator: Comprehensive Care Physician (CCP)
  Patients randomized to the CCP group are assigned to a Comprehensive Care Physician and are asked to see their assigned CCP for their primary care. The patients receive their care from the same CCP in the outpatient clinic and also if they were to be hospitalized.
• Active Comparator: Comprehensive Care, Community & Culture Program (C4P)
  Patients randomized to C4P receive care from a CCP in both the hospital and the clinic as well as the following: 1) systematic screening of 17 domains of unmet social needs, 2) access to a community health worker and 3) access to community-based arts and culture programming.

Primary Outcome Measure

Quarterly hospitalization rate [ Time Frame: Through study completion, with a range of 1 to 4.5 years ]

Locations (1)

Find similar trials in Chicago, IL

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