Connecting Low-Income Adults to Primary Care After Inpatient Discharge

Vanderbilt University Medical Center200 enrolled

Overview

Healthcare systems and insurers have tried to reduce costs by improving the care and coordination provided to patients with high healthcare spending. Often termed, "hotspotting", these interventions seek to lower costs by reducing care provided in fragmented, high-cost settings, including the emergency department and inpatient settings, by addressing the social determinants of health and improving patients' access to lower-cost, ambulatory settings. Vanderbilt University Medical Center (VUMC), in collaboration with Tennessee's Medicaid agency (TennCare), is piloting a program to reduce costs and improve the quality of care provided to high-risk TennCare enrollees by referring them from inpatient settings to VUMC primary care services. This study seeks to evaluate this pilot by comparing outcomes between Medicaid patients referred to VUMC primary care services and similar Medicaid patients not referred to VUMC primary care services using data from surveys and administrative sources, including electronic health records and health insurance claims.

Study Type

OBSERVATIONAL

Enrollment

200

Conditions

Health Care Utilization Health Care Seeking Behavior

Interventions

Those in the pilot group will be referred to primary care services and allowed to utilize them for at least two years. Primary care services include access to a primary care physician, medical management, and other tasks typically performed by a general practitioner. Those referred to primary care services will not have access to other VUMC outpatient services.

Eligibility

Sex: ALLMin age: 18 Years

Medical Language ↔ Plain English

Inclusion Criteria: * Age 18 or older * Currently enrolled in Tennessee's Medicaid Program (TennCare) * Presenting in VUMC's inpatient setting * Reporting no active relationship with a primary care doctor * Lives in Davidson County, Tennessee, or a surrounding county Exclusion Criteria: * Patients discharged to a setting other than the community (e.g. to a Skilled Nursing Facility)