Background
Approximately 25% of U.S. adults live with two or more chronic physical and/or behavioral health conditions. As the population continues to age, the increasing prevalence of those living with multiple chronic conditions (MCC) is a growing public health concern. Those with MCCs, many of whom are publicly-insured, use substantial amounts of health services, and are more likely to be admitted to the hospital due to complications associated with their conditions. These conditions also place an incredible amount of stress on individuals with MCCs and their caregivers, leading to a lower overall quality of life. See our clinicaltrials.gov profile and PCORI® project description for more details.
Healthcare Challenge
While there is evidence that shows integrated care models can improve outcomes for those with MCCs, they have yet to be widely implemented. This study compares three ways health systems can deploy resources and care management support to individuals with MCCs after a hospital stay to better manage their future health.
Goals
At the end of this study, we hope to be able to better answer the following questions:
- How do in-person and remote monitoring care management programs influence patient-centered outcomes? For example, which mode of care management delivery helps people living with MCCs to better manage their conditions at home and/or go to the hospital less frequently?
- What mode of care delivery works best for whom? For example, do adults over the age of 60 benefit more from an in-person approach? When is a remote monitoring approach most impactful for improving someone’s ability to manage their health?
- What supports someone’s engagement in care management? What are barriers to working with care managers who deliver care in-person or remotely?
Implementation Approach
Population
Health Plan Members, ages 21 and over, with multiple chronic conditions— including one physical health condition and at least one additional physical or behavioral health condition— who have been discharged from an inpatient hospital stay within the past 30 days.
Methodology
This randomized controlled trial compares the impact of three different modes of care delivery on hospital readmission, health status, and patient activation.
- Optimal Discharge Planning (ODP): use of in-person and telephonic modalities, for two weeks, to engage members in care management, and if needed, an additional two weeks for resource connection.
- High-Touch: use of in-person and telephonic modalities, for four to 12 months, to engage members in care management.
- High-Tech: use of remote patient monitoring (RPM) and telephonic modalities, for four to 12 months, to engage members in care management.
Participants completed surveys at the time of enrollment, and at 3, 6, and 12-month timepoints to report on changes in health status, patient activation, physical function, quality of life, and care satisfaction.
Both participants and care management staff completed qualitative interviews to share about challenges and benefits to engaging and/or implementing High-Tech and High-Touch care management strategies. The study design, implementation, and results interpretation are advised by a patient partner workgroup, a patient-partner co-investigator, and an advisory board of health providers, caregivers, patients, researchers, payers, policy makers, and community organizations.
This project was funded through the Patient-Centered Outcomes Research Institute® (PCORI®) Award IHS-1609-36670. The views, statements, and opinions presented in this webpage are solely the responsibility of the author(s) and do not necessarily represent the views of PCORI®