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Care in the Comprehensive Care Physician (CCP) program vs. care in the Comprehensive Care, Community, and Culture Program (C4P) vs. care in traditional care coordinator program
Investigator (PI): Meltzer, David O
Performing Organization (PO): (Current): University of Chicago, Pritzker School of Medicine, Department of Medicine, Section of Hospital Medicine / (773) 702-5173
Supporting Agency (SA): Patient-Centered Outcomes Research Institute (PCORI)
Initial Year: 2020
Final Year: 2024
Record Source/Award ID: PCORI/AD-2019C1-16074
Funding: Total Award Amount: $4,202,799
Award Type: Contract
Award Information: PCORI: More information and project results (when completed)
Abstract: The health of communities and health disparities are influenced both by the health care system and by the social context in which people live. Accordingly, interventions that seek to meaningfully reduce disparities should consider patients' medical and social needs. The fragmentation of medical care is one aspect of the health care system that adversely affects health, perhaps particularly for socioeconomically disadvantaged individuals with more limited resources to bridge gaps in care. Indeed, while many care coordination programs have been developed, evidence supporting their effectiveness is quite limited, especially for vulnerable populations. This study will fill important gaps in evidence concerning the effects of 3 diverse care coordination models on hospitalization rates for a socioeconomically disadvantaged population at increased risk of hospitalization that is served by University of Chicago Medicine (UCM). Secondary outcomes include patient activation and engagement with care, satisfaction with care, general health and mental health, and personal goal attainment. The first model is a commonly implemented care coordination model developed and studied by Partners HealthCare which we call the Partners HealthCare Care Management Program (PHCMP). In PHCMP, "high-risk" patients have access to nurse care coordinators who seek to manage these patients' care across the continuum. UCM has recently implemented a model based on PHCMP which it calls the Ambulatory Care Coordination Team (ACCT). In ACCT, nurses and social workers provide proactive care coordination to high-risk patients. Both programs are representative of common care coordination models implemented nationally in that they involve additional hiring and increased handoffs. The second model is a novel care delivery program called the Comprehensive Care Physician (CCP) program. The CCP model seeks to more effectively integrate inpatient and outpatient care for patients at increased risk of hospitalization by offering them care from the same physician in the inpatient and the outpatient settings so that they can benefit from the advantages of continuity in the doctor patient relationship. Since 2012, we have developed and tested this model at UCM in a socioeconomically disadvantaged population of patients at increased risk of hospitalization through a randomized controlled trial funded by the Center for Medicare and Medicaid Innovation that compares CCP to standard care (SC) at UCM in which patients receive inpatient and outpatient care from different doctors and do not have access to care coordinators. Our findings to date indicate that CCP significantly improves patient satisfaction and outcomes and decreases resource use. We think that these improved outcomes stem from the greater continuity of care our CCP physicians and team are able to provide patients because they care for them in and out of the hospital. The third model, the Comprehensive Care, Community, and Culture Program (C4P), was motivated by the finding that ~30% of patients who enrolled in the CCP program did not engage with it despite having expressed interest in the program and that a wide range of social factors might be barriers to their engagement. To better address social determinants of health, C4P builds on CCP by adding 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. Preliminary findings from a pilot of C4P indicate that C4P increases patient activation and engagement in care compared to SC. While we have rigorously compared CCP to SC and performed a pilot study of C4P, CCP, and SC at UCM, we have not compared CCP or C4P to the more commonly-used CC model nor have we rigorously compared CCP and C4P. The rigorous findings comparing these models that we propose to generate are sorely needed by patients and health systems to inform choices about care coordination models, and particularly for socioeconomically disadvantaged individuals. In this study, we aim to determine primarily whether socioeconomically disadvantaged Medicare patients at increased risk of hospitalization experience fewer hospitalizations if they 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. We also will determine how these programs affect patient activation and engagement in care, satisfaction with care, general health and mental health, and goal attainment.
MeSH Terms:
  • Academic Medical Centers
  • Access to Health Care
  • Case Management
  • Chicago
  • Continuity of Patient Care
  • Health Services Research
  • Hospitalization
  • Humans
  • Integrated Health Care Systems /*organization & administration
  • Interdisciplinary Communication
  • Medicare
  • Nurses
  • Organizational Models
  • * Patient Care Team
  • Patient Handoff
  • Patient Satisfaction
  • Poverty
  • Risk
  • Social Determinants of Health
  • Social Workers
  • Socioeconomic Status
Country: United States
State: Illinois
Zip Code: 60637
UI: 20202765
Project Status: Ongoing