Coventry Outcomes Study of Seniors (COSS): A Comparative Effectiveness Study to Evaluate the Effect of a Multidisciplinary Team's Intervention on the Incidence of Nonelective Hospitalizations in a Medicare Population

Study Results

Results pending

The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.

Basic Information

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Recruitment Status

TERMINATED

Clinical Phase

NA

Total Enrollment

2150 participants

Study Classification

INTERVENTIONAL

Study Start Date

2009-11-30

Study Completion Date

2011-06-30

Brief Summary

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The investigators are studying the impact of the interventions of a multidisciplinary team (MDT) - consisting of a Coventry case manager, social worker, and medical director, alongside a Medco specialist pharmacist - on the hospitalization rates of high risk seniors with chronic conditions, compared with a usual care approach. The study will also examine the impact on quality of life, medication adherence, medical costs, hospital readmission rates, and a variety of other important measures. The outcome of COSS may support a means to further enhance and develop a comprehensive care model program by leveraging the partnership between a health plan and a pharmacy benefit manager.

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Detailed Description

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The multidisciplinary team will provide face-to-face visits in a home setting with interventions that focus on five key areas: care transitions, self-management, care coordination, pharmacy and prevention, all designed to support high-risk Medicare members and their relationship with their primary care providers. If the study proves to reduce hospitalizations in the senior population, it could provide important guidance for future efforts to reduce the cost and improve the quality of care for seniors with chronic conditions.

Conditions

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Heart Failure Chronic Obstructive Pulmonary Disease Cardiovascular Disease Diabetes Osteoporosis

Study Groups

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Control Group

The control group will receive usual care as provided by your Health Plan.

Group Type OTHER

Usual case management and pharmacy management as provided by the health Plan and the pharmacy benefit manager

Intervention Type OTHER

Intervention group

Additional visits will be conducted by a member of the multidisciplinary team (case manager/nurse, social worker and/or pharmacist that will be either face to face or by telephone.

Group Type OTHER

Multidisciplinary team interventions

Intervention Type OTHER

The multidisciplinary team will determine which intervention should be applied to the participant in the intervention group based on their health risk assessment responses as well as medication review and visual inspection of the home.

Multidisciplinary team bimonthly visits either in person or via telephone.

Intervention Type OTHER

Interventions

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Multidisciplinary team interventions

The multidisciplinary team will determine which intervention should be applied to the participant in the intervention group based on their health risk assessment responses as well as medication review and visual inspection of the home.

Intervention Type OTHER

Multidisciplinary team bimonthly visits either in person or via telephone.

Intervention Type OTHER

Usual case management and pharmacy management as provided by the health Plan and the pharmacy benefit manager

Intervention Type OTHER

Eligibility Criteria

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Inclusion Criteria

* Inouye Risk Score \>3 calculated on Coventry Claims
* Medicare Advantage beneficiaries age \> 65 years
* Continuous eligibility \> 12 months prior to study
* Ability to be contacted via telephone
* Subject is willing and able to provide informed consent
* Willing to comply with all study procedures and be available for the duration of the study

Exclusion Criteria

* Active cancer treatment (i.e. chemotherapy or radiation) in the past 6 months
* Living anywhere other than a community setting \[i.e. Skilled nursing facility (SNF)\]
* Just-In-Time (JIT) Members
* Members with a geographic location \> 60 from either St. Louis or Kansas City, MO.
* Solid organ transplant recipients
* Active enrollment in another clinical research study

Minimum Eligible Age

65 Years

Eligible Sex

ALL

Accepts Healthy Volunteers

No