The CommunityRx system generates patient-centered e-prescriptions for community services (HealtheRx) via an interface between the electronic health records (EHR) and a comprehensive community resource database. Based on a patient's diagnoses, a HealtheRx will be printed automatically at the end of the ambulatory care visit and will provide patients with a customized map and/or list of places in their community that provide health and social services as well as contact information for a local community health worker who can provide limited case management support. The CommunityRx program aims to promote: 1) better healthcare, 2) better health, and 3) lower cost. The purpose of this research is to systematically evaluate the impact of CommunityRx on health outcomes as well as health care service utilization and total cost of care for Medicaid, Medicare and other beneficiaries. The investigators hypothesize that beneficiaries who participate in the CommunityRx intervention will experience better healthcare, better health and lower total cost of care.
Study Type
INTERVENTIONAL
Allocation
NON_RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
113,295
The HealtheRx is a prescription for community self-care resources. It includes a printed list of self-care resources provided to the patient at an ambulatory visit and tailored based on data from the electronic medical record.
University of Chicago
Chicago, Illinois, United States
Change in cost per beneficiary per year
Cost per beneficiary per year
Time frame: Annual, up to 6 years
Change in emergency department visit rate
Hospital emergency department visit rate, overall and for patients diagnosed with a) diabetes, b) hypertension, and c) asthma
Time frame: Every 3 months, up to 72 months
Change in HbA1c control
Percentage of patients 18-75 years of age with diabetes (type 1 or type 2) who had hemoglobin A1c \> 9.0 %.
Time frame: Every 3 months, up to 72 months
Change in controlling high blood pressure
% of patients \>=18 years old with hypertension diagnosis and a most recent BP measure \<140/90mg
Time frame: Every 3 months, up to 72 months
Change in body mass index
Percentage of patients overweight or obese (BMI \>=25.0 and \<30, BMI \>=30)
Time frame: Every 3 months, up to 72 months
Change in inpatient admission rate
Average number of in patient admissions per person
Time frame: Every 3 months, up to 72 months
Change in participant satisfaction (percentage of participants reporting they are satisfied with the HealtheRx)
Program participant satisfaction survey, percentage of participants reporting they are satisfied with the HealtheRx
Time frame: Every 3 months, up to 60 months
Change in provider satisfaction ( percent of providers reporting they are satisfied with the HealtheRx system)
Provider satisfaction survey, percent of providers reporting they are satisfied with the HealtheRx system
Time frame: Every 6 months, up to 60 months
Change in rate of participant use of community-based service providers listed on HealtheRx
Program participant survey, percent of participants who report using at least 1 service listed on their HealtheRx
Time frame: Every 3 months, up to 60 months
Change in HealtheRx reach (proportion of the population in the geography who receive at least 1 HealtheRx)
The proportion of the population in the geography who receive at least 1 HealtheRx
Time frame: Every 3 months, up to 60 months
Change in HealtheRx delivery (providers communicate to patients about the HealtheRx)
providers communicate to patients about the HealtheRx
Time frame: Every 3 months, up to 60 months
Change in HealtheRx usefulness (participant survey, the percent of program participants who report that their HealtheRx is useful)
Program participant survey, the percent of program participants who report that their HealtheRx is useful
Time frame: Every 3 months, up to 60 months
Change in HealtheRx Understandability (participant survey, the percent of program participants who report that their HealtheRx is easy to understand)
Program participant survey, the percent of program participants who report that their HealtheRx is easy to understand
Time frame: Every 3 months, up to 60 months
Change in information sharing (participant survey, the percent of program participants who report that they shared information about the HealtheRx with someone else)
Program participant survey, the percent of program participants who report that they shared information about the HealtheRx with someone else
Time frame: Every 3 months, up to 60 months
Change in knowledge about resources (participant survey, the percent of program participants who report that they did not know about some of the places listed on their HealtheRx)
Program participant survey, the percent of program participants who report that they did not know about some of the places listed on their HealtheRx
Time frame: Every 3 months, up to 60 months
Change in provider confidence in serving social needs (Provider satisfaction survey,)
Provider satisfaction survey, the proportion of providers reporting they are confident in their ability to serve their patients social needs
Time frame: Every 6 months, up to 60 months
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