Transforming Outcomes for Patients Through Medical Home Evaluation & reDesign

Care Management Plus65,500 enrolled

Overview

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: 1. Evidence-based Care Management Based on Need 2. Identification of At-Risk Populations 3. Patient Engagement and Alerts Based on Goals 4. Integrated Information for Care Management, especially around Utilization 5. Population Management Tools

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

SUPPORTIVE_CARE

Masking

SINGLE

Enrollment

65,500

Conditions

Nurse Based Care Management

Eligibility

Sex: ALLMin age: 18 Years

Medical Language ↔ Plain English

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

Outcomes

Primary Outcomes

Preventable utilization

Reduce by 15% ED visits and hospitalizations related to ambulatory care

Time frame: 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.)

Time frame: 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.

Time frame: 12 months

Transforming Outcomes for Patients Through Medical Home Evaluation & reDesign

Overview

Conditions

Interventions

Eligibility

Locations (1)

Outcomes

Primary Outcomes