Trial Outcomes & Findings for Integrated Care (IC) Models for Patient-Centered Outcomes (NCT NCT03451630)
NCT ID: NCT03451630
Last Updated: 2024-12-09
Results Overview
Assessed using the Patient Activation Measure (PAM), a 13-item scale that gauges individual knowledge, skills, and confidence essential to managing one's own health. We assess a global score of the PAM measure, with scores ranging from 0 to 100; lower values represent a poor outcome while higher values represent a better outcome.
COMPLETED
NA
1400 participants
Baseline, 3-, 6-, and 12-months.
2024-12-09
Participant Flow
Enrollment occurred between September 4, 2018 and November 4, 2021. Care Managers enrolled eligible individuals during an initial in-home or telephonic visit; a study team member conducted randomization.
Participant milestones
| Measure |
High-Touch
Delivered primarily via face-to-face interactions, with telephonic interactions and information sharing that does not require access to mobile devices or the Internet. In-person support and/or telephonic interactions to occur at least four times over at least a four-month period.
High-Touch: Intensive, in-person and/or telephonic support.
|
High-Tech
Delivered via a remote care management platform and digital health tools. Remote care support interactions to occur for at least a four-month period.
High-Tech: Remote care management and self-directed digital tools.
|
Optimal Discharge Planning
Delivered via Health Plan support and resources within 14-30 days of an initial home or telephonic visit.
Optimal Discharge Planning: Transition to other Health Plan disease management programs and/or community resources.
|
|---|---|---|---|
|
Overall Study
STARTED
|
562
|
552
|
286
|
|
Overall Study
COMPLETED
|
535
|
529
|
268
|
|
Overall Study
NOT COMPLETED
|
27
|
23
|
18
|
Reasons for withdrawal
| Measure |
High-Touch
Delivered primarily via face-to-face interactions, with telephonic interactions and information sharing that does not require access to mobile devices or the Internet. In-person support and/or telephonic interactions to occur at least four times over at least a four-month period.
High-Touch: Intensive, in-person and/or telephonic support.
|
High-Tech
Delivered via a remote care management platform and digital health tools. Remote care support interactions to occur for at least a four-month period.
High-Tech: Remote care management and self-directed digital tools.
|
Optimal Discharge Planning
Delivered via Health Plan support and resources within 14-30 days of an initial home or telephonic visit.
Optimal Discharge Planning: Transition to other Health Plan disease management programs and/or community resources.
|
|---|---|---|---|
|
Overall Study
Death
|
15
|
16
|
11
|
|
Overall Study
Lost to Follow-up
|
9
|
0
|
4
|
|
Overall Study
Withdrawal by Subject
|
0
|
3
|
0
|
|
Overall Study
Unable to confirm accurate eligibility criteria after randomization and intervention completion.
|
3
|
4
|
3
|
Baseline Characteristics
Integrated Care (IC) Models for Patient-Centered Outcomes
Baseline characteristics by cohort
| Measure |
High-Touch
n=559 Participants
Delivered primarily via face-to-face interactions, with telephonic interactions and information sharing that does not require access to mobile devices or the Internet. In-person support and/or telephonic interactions to occur at least four times over at least a four-month period.
High-Touch: Intensive, in-person and/or telephonic support.
|
High-Tech
n=545 Participants
Delivered via a remote care management platform and digital health tools. Remote care support interactions to occur for at least a four-month period.
High-Tech: Remote care management and self-directed digital tools.
|
Optimal Discharge Planning
n=283 Participants
Delivered via Health Plan support and resources within 14-30 days of an initial home or telephonic visit.
Optimal Discharge Planning: Transition to other Health Plan disease management programs and/or community resources.
|
Total
n=1387 Participants
Total of all reporting groups
|
|---|---|---|---|---|
|
Age, Continuous
|
52.87 years
STANDARD_DEVIATION 11.68 • n=5 Participants
|
53.59 years
STANDARD_DEVIATION 11.59 • n=7 Participants
|
53.67 years
STANDARD_DEVIATION 12.08 • n=5 Participants
|
53.32 years
STANDARD_DEVIATION 11.72 • n=4 Participants
|
|
Sex: Female, Male
Female
|
341 Participants
n=5 Participants
|
345 Participants
n=7 Participants
|
188 Participants
n=5 Participants
|
874 Participants
n=4 Participants
|
|
Sex: Female, Male
Male
|
218 Participants
n=5 Participants
|
200 Participants
n=7 Participants
|
95 Participants
n=5 Participants
|
513 Participants
n=4 Participants
|
|
Ethnicity (NIH/OMB)
Hispanic or Latino
|
15 Participants
n=5 Participants
|
15 Participants
n=7 Participants
|
9 Participants
n=5 Participants
|
39 Participants
n=4 Participants
|
|
Ethnicity (NIH/OMB)
Not Hispanic or Latino
|
544 Participants
n=5 Participants
|
530 Participants
n=7 Participants
|
274 Participants
n=5 Participants
|
1348 Participants
n=4 Participants
|
|
Ethnicity (NIH/OMB)
Unknown or Not Reported
|
0 Participants
n=5 Participants
|
0 Participants
n=7 Participants
|
0 Participants
n=5 Participants
|
0 Participants
n=4 Participants
|
|
Race (NIH/OMB)
American Indian or Alaska Native
|
7 Participants
n=5 Participants
|
5 Participants
n=7 Participants
|
3 Participants
n=5 Participants
|
15 Participants
n=4 Participants
|
|
Race (NIH/OMB)
Asian
|
1 Participants
n=5 Participants
|
0 Participants
n=7 Participants
|
0 Participants
n=5 Participants
|
1 Participants
n=4 Participants
|
|
Race (NIH/OMB)
Native Hawaiian or Other Pacific Islander
|
1 Participants
n=5 Participants
|
3 Participants
n=7 Participants
|
0 Participants
n=5 Participants
|
4 Participants
n=4 Participants
|
|
Race (NIH/OMB)
Black or African American
|
122 Participants
n=5 Participants
|
120 Participants
n=7 Participants
|
57 Participants
n=5 Participants
|
299 Participants
n=4 Participants
|
|
Race (NIH/OMB)
White
|
414 Participants
n=5 Participants
|
394 Participants
n=7 Participants
|
204 Participants
n=5 Participants
|
1012 Participants
n=4 Participants
|
|
Race (NIH/OMB)
More than one race
|
10 Participants
n=5 Participants
|
8 Participants
n=7 Participants
|
9 Participants
n=5 Participants
|
27 Participants
n=4 Participants
|
|
Race (NIH/OMB)
Unknown or Not Reported
|
4 Participants
n=5 Participants
|
15 Participants
n=7 Participants
|
10 Participants
n=5 Participants
|
29 Participants
n=4 Participants
|
|
Charlson Comorbidity Index (CCI)
|
4.94 units on a scale
STANDARD_DEVIATION 3.23 • n=5 Participants
|
5.14 units on a scale
STANDARD_DEVIATION 3.07 • n=7 Participants
|
5.16 units on a scale
STANDARD_DEVIATION 3.42 • n=5 Participants
|
5.06 units on a scale
STANDARD_DEVIATION 3.21 • n=4 Participants
|
|
Area Deprivation Index (ADI)
|
109.64 units on a scale
STANDARD_DEVIATION 5.29 • n=5 Participants
|
109.45 units on a scale
STANDARD_DEVIATION 5.62 • n=7 Participants
|
109.60 units on a scale
STANDARD_DEVIATION 5.11 • n=5 Participants
|
109.56 units on a scale
STANDARD_DEVIATION 5.38 • n=4 Participants
|
|
Comfort with Technology/ Digital Literacy
Comfortable: Disagree Strongly
|
33 Participants
n=5 Participants
|
41 Participants
n=7 Participants
|
16 Participants
n=5 Participants
|
90 Participants
n=4 Participants
|
|
Comfort with Technology/ Digital Literacy
Comfortable: Disagree
|
85 Participants
n=5 Participants
|
70 Participants
n=7 Participants
|
35 Participants
n=5 Participants
|
190 Participants
n=4 Participants
|
|
Comfort with Technology/ Digital Literacy
Comfortable: Agree
|
310 Participants
n=5 Participants
|
296 Participants
n=7 Participants
|
162 Participants
n=5 Participants
|
768 Participants
n=4 Participants
|
|
Comfort with Technology/ Digital Literacy
Comfortable: Agree Strongly
|
131 Participants
n=5 Participants
|
138 Participants
n=7 Participants
|
70 Participants
n=5 Participants
|
339 Participants
n=4 Participants
|
|
Line of Business (Medicaid/ Medicaid-Medicare)
Medicare-Medicaid
|
118 Participants
n=5 Participants
|
107 Participants
n=7 Participants
|
59 Participants
n=5 Participants
|
284 Participants
n=4 Participants
|
|
Line of Business (Medicaid/ Medicaid-Medicare)
Medicaid
|
441 Participants
n=5 Participants
|
438 Participants
n=7 Participants
|
224 Participants
n=5 Participants
|
1103 Participants
n=4 Participants
|
|
Engagement at Baseline
No
|
215 Participants
n=5 Participants
|
213 Participants
n=7 Participants
|
246 Participants
n=5 Participants
|
674 Participants
n=4 Participants
|
|
Engagement at Baseline
Yes
|
344 Participants
n=5 Participants
|
332 Participants
n=7 Participants
|
37 Participants
n=5 Participants
|
713 Participants
n=4 Participants
|
PRIMARY outcome
Timeframe: Baseline, 3-, 6-, and 12-months.Population: Includes all individuals who completed the measure at least one timepoint.
Assessed using the Patient Activation Measure (PAM), a 13-item scale that gauges individual knowledge, skills, and confidence essential to managing one's own health. We assess a global score of the PAM measure, with scores ranging from 0 to 100; lower values represent a poor outcome while higher values represent a better outcome.
Outcome measures
| Measure |
High-Touch
n=495 Participants
Delivered primarily via face-to-face interactions, with telephonic interactions and information sharing that does not require access to mobile devices or the Internet. In-person support and/or telephonic interactions to occur at least four times over at least a four-month period.
High-Touch: Intensive, in-person and/or telephonic support.
|
High-Tech
n=506 Participants
Delivered via a remote care management platform and digital health tools. Remote care support interactions to occur for at least a four-month period.
High-Tech: Remote care management and self-directed digital tools.
|
Optimal Discharge Planning
n=237 Participants
Delivered via Health Plan support and resources within 14-30 days of an initial home or telephonic visit.
Optimal Discharge Planning: Transition to other Health Plan disease management programs and/or community resources.
|
|---|---|---|---|
|
Patient Activation
Baseline
|
61.87 score on a scale
Standard Deviation 14.36
|
63.73 score on a scale
Standard Deviation 16.10
|
63.82 score on a scale
Standard Deviation 16.12
|
|
Patient Activation
3-Months
|
63.15 score on a scale
Standard Deviation 15.56
|
63.60 score on a scale
Standard Deviation 16.65
|
63.60 score on a scale
Standard Deviation 15.98
|
|
Patient Activation
6-Months
|
62.55 score on a scale
Standard Deviation 16.03
|
62.15 score on a scale
Standard Deviation 15.84
|
64.76 score on a scale
Standard Deviation 15.98
|
|
Patient Activation
12-Months
|
63.15 score on a scale
Standard Deviation 15.05
|
64.58 score on a scale
Standard Deviation 15.41
|
62.83 score on a scale
Standard Deviation 15.75
|
PRIMARY outcome
Timeframe: Baseline, 3-, 6-, and 12-months.Population: Includes all individuals who completed the measure at least one timepoint.
Assessed using the RAND 36-Item Short Form Survey 1.0 (SF-36). The SF-36 is a set of 36 health status and quality-of-life measures that are patient self-reported and measure functional health and well-being within eight domains, including physical functioning, role limitations due to physical health, role limitations due to emotional problems, energy/fatigue, emotional well-being, social functioning, pain, and general health. Values are recoded per the scoring key relating each item to the appropriate subscale. All items are scored so that a high score defines a more favorable health state. We assess a global scale with a 0 to 100 range with 0 being worst possible health status and 100 being the best possible health status.
Outcome measures
| Measure |
High-Touch
n=496 Participants
Delivered primarily via face-to-face interactions, with telephonic interactions and information sharing that does not require access to mobile devices or the Internet. In-person support and/or telephonic interactions to occur at least four times over at least a four-month period.
High-Touch: Intensive, in-person and/or telephonic support.
|
High-Tech
n=505 Participants
Delivered via a remote care management platform and digital health tools. Remote care support interactions to occur for at least a four-month period.
High-Tech: Remote care management and self-directed digital tools.
|
Optimal Discharge Planning
n=236 Participants
Delivered via Health Plan support and resources within 14-30 days of an initial home or telephonic visit.
Optimal Discharge Planning: Transition to other Health Plan disease management programs and/or community resources.
|
|---|---|---|---|
|
Change in Health Status
6-Month
|
41.86 score on a scale
Standard Deviation 19.84
|
41.39 score on a scale
Standard Deviation 19.84
|
41.83 score on a scale
Standard Deviation 20.84
|
|
Change in Health Status
12-Month
|
42.68 score on a scale
Standard Deviation 20.50
|
42.27 score on a scale
Standard Deviation 19.63
|
40.85 score on a scale
Standard Deviation 19.03
|
|
Change in Health Status
Baseline
|
39.61 score on a scale
Standard Deviation 18.39
|
39.50 score on a scale
Standard Deviation 18.65
|
39.05 score on a scale
Standard Deviation 17.80
|
|
Change in Health Status
3-Month
|
42.12 score on a scale
Standard Deviation 20.06
|
42.03 score on a scale
Standard Deviation 19.90
|
41.31 score on a scale
Standard Deviation 19.99
|
PRIMARY outcome
Timeframe: 1 to 90 daysPopulation: 8 participants (0.57%) have missing readmission data. Since 31 participants had more than one admission within 90 days, a binary indicator of readmission within 90 days was generated and used as a primary outcome.
90-Day Readmissions will be measured using an all-cause readmission rate from inpatient claims for physical and behavioral health service use within 90 days following discharge from the qualifying inpatient admission prior to enrollment in the study.
Outcome measures
| Measure |
High-Touch
n=557 Participants
Delivered primarily via face-to-face interactions, with telephonic interactions and information sharing that does not require access to mobile devices or the Internet. In-person support and/or telephonic interactions to occur at least four times over at least a four-month period.
High-Touch: Intensive, in-person and/or telephonic support.
|
High-Tech
n=541 Participants
Delivered via a remote care management platform and digital health tools. Remote care support interactions to occur for at least a four-month period.
High-Tech: Remote care management and self-directed digital tools.
|
Optimal Discharge Planning
n=281 Participants
Delivered via Health Plan support and resources within 14-30 days of an initial home or telephonic visit.
Optimal Discharge Planning: Transition to other Health Plan disease management programs and/or community resources.
|
|---|---|---|---|
|
90-Day Hospital Readmission Rate
No readmission within 90 days
|
472 Participants
|
470 Participants
|
240 Participants
|
|
90-Day Hospital Readmission Rate
At least one readmission within 90 days
|
85 Participants
|
71 Participants
|
41 Participants
|
SECONDARY outcome
Timeframe: 1 to 30 daysPopulation: Since only 2 participants had more than one admission (2 admissions) within 30 days, a binary indicator of readmission within 30 days was generated and used as the outcome.
30-Day Readmissions will be measured using an all-cause readmission rate in claims for physical and behavioral health service use within 30 days following discharge from the qualifying inpatient admission prior to enrollment in the study.
Outcome measures
| Measure |
High-Touch
n=559 Participants
Delivered primarily via face-to-face interactions, with telephonic interactions and information sharing that does not require access to mobile devices or the Internet. In-person support and/or telephonic interactions to occur at least four times over at least a four-month period.
High-Touch: Intensive, in-person and/or telephonic support.
|
High-Tech
n=545 Participants
Delivered via a remote care management platform and digital health tools. Remote care support interactions to occur for at least a four-month period.
High-Tech: Remote care management and self-directed digital tools.
|
Optimal Discharge Planning
n=283 Participants
Delivered via Health Plan support and resources within 14-30 days of an initial home or telephonic visit.
Optimal Discharge Planning: Transition to other Health Plan disease management programs and/or community resources.
|
|---|---|---|---|
|
30-Day Hospital Readmission Rate
No readmission within 30 days
|
535 Participants
|
528 Participants
|
272 Participants
|
|
30-Day Hospital Readmission Rate
At least one readmission within 30 days
|
24 Participants
|
17 Participants
|
11 Participants
|
SECONDARY outcome
Timeframe: Baseline, 3-, 6-, and 12-months.Population: Includes all individuals who completed the measure at least one timepoint.
Assessed using the PROMIS Physical Function - Short Form 6b with six self-reported physical function measures to assess current function, including activities of daily living. Each question has five response options (a 5-point Likert scale) ranging from one to five with 5 being the highest level of physical function and 1 being the lowest. Per best practices, the instrument is scored by Health Measures Scoring Service, using item-level calibrations using responses to each item for each participant, producing a T-score. The highest possible T-score score is 59, indicating the highest level of physical function, and the lowest is 21, indicating the lowest level of physical function.
Outcome measures
| Measure |
High-Touch
n=478 Participants
Delivered primarily via face-to-face interactions, with telephonic interactions and information sharing that does not require access to mobile devices or the Internet. In-person support and/or telephonic interactions to occur at least four times over at least a four-month period.
High-Touch: Intensive, in-person and/or telephonic support.
|
High-Tech
n=494 Participants
Delivered via a remote care management platform and digital health tools. Remote care support interactions to occur for at least a four-month period.
High-Tech: Remote care management and self-directed digital tools.
|
Optimal Discharge Planning
n=224 Participants
Delivered via Health Plan support and resources within 14-30 days of an initial home or telephonic visit.
Optimal Discharge Planning: Transition to other Health Plan disease management programs and/or community resources.
|
|---|---|---|---|
|
Functional Status
6-Month
|
37.30 T score
Standard Deviation 7.87
|
36.85 T score
Standard Deviation 7.76
|
37.24 T score
Standard Deviation 7.91
|
|
Functional Status
12-Month
|
36.99 T score
Standard Deviation 8.65
|
36.73 T score
Standard Deviation 8.14
|
36.29 T score
Standard Deviation 7.66
|
|
Functional Status
Baseline
|
36.75 T score
Standard Deviation 7.89
|
36.29 T score
Standard Deviation 7.98
|
35.78 T score
Standard Deviation 7.60
|
|
Functional Status
3-Month
|
37.11 T score
Standard Deviation 7.65
|
37.02 T score
Standard Deviation 7.97
|
36.83 T score
Standard Deviation 8.20
|
SECONDARY outcome
Timeframe: Baseline, 3-, 6-, and 12-months.Population: Includes all individuals who completed the measure at least one timepoint.
Quality of Life will be assessed using the Quality of Life Enjoyment and Satisfaction Questionnaire - Short Form (Q-LES-Q-SF), which is a self-report measure consisting of 16 questions designed to enable investigators to easily obtain sensitive measures of the degree of enjoyment and satisfaction experienced by subjects in various areas of daily functioning during the past week. The scoring of the Q-LES-Q-SF involves summing only the first 14 items to yield a raw total score, ranging from 14 to 70. The raw total score is calculated into a maximum possible score using the following formula: (raw total score - minimum score)/(maximum possible raw score - minimum score). The minimum raw score on the Q-LES-Q-SF is 14, and the maximum score is 70. Thus, the formula for maximum score can also be written as: (raw score - 14)/56.
Outcome measures
| Measure |
High-Touch
n=492 Participants
Delivered primarily via face-to-face interactions, with telephonic interactions and information sharing that does not require access to mobile devices or the Internet. In-person support and/or telephonic interactions to occur at least four times over at least a four-month period.
High-Touch: Intensive, in-person and/or telephonic support.
|
High-Tech
n=504 Participants
Delivered via a remote care management platform and digital health tools. Remote care support interactions to occur for at least a four-month period.
High-Tech: Remote care management and self-directed digital tools.
|
Optimal Discharge Planning
n=236 Participants
Delivered via Health Plan support and resources within 14-30 days of an initial home or telephonic visit.
Optimal Discharge Planning: Transition to other Health Plan disease management programs and/or community resources.
|
|---|---|---|---|
|
Quality of Life
12-Month
|
0.54 score on a scale
Standard Deviation 0.20
|
0.52 score on a scale
Standard Deviation 0.19
|
0.53 score on a scale
Standard Deviation 0.19
|
|
Quality of Life
Baseline
|
0.50 score on a scale
Standard Deviation 0.19
|
0.51 score on a scale
Standard Deviation 0.19
|
0.51 score on a scale
Standard Deviation 0.21
|
|
Quality of Life
3-Month
|
0.52 score on a scale
Standard Deviation 0.19
|
0.52 score on a scale
Standard Deviation 0.19
|
0.52 score on a scale
Standard Deviation 0.20
|
|
Quality of Life
6-Month
|
0.52 score on a scale
Standard Deviation 0.20
|
0.52 score on a scale
Standard Deviation 0.20
|
0.52 score on a scale
Standard Deviation 0.21
|
SECONDARY outcome
Timeframe: Baseline, 3-, 6-, and 12-months.Population: Includes all individuals who completed the measure at least one timepoint.
Care satisfaction will be assessed using the Patient Assessment of Care for Chronic Conditions (PACIC) Survey. The PACIC Survey consists of 20-items that measures specific actions or qualities of care that patients report they have experienced in the care of their chronic conditions over the past 6 months. Each item is measured on a scale from 1-5 with 5 signifying higher patient satisfaction and 1 being the lowest. Scoring requires obtaining the mean of all 20 items.
Outcome measures
| Measure |
High-Touch
n=492 Participants
Delivered primarily via face-to-face interactions, with telephonic interactions and information sharing that does not require access to mobile devices or the Internet. In-person support and/or telephonic interactions to occur at least four times over at least a four-month period.
High-Touch: Intensive, in-person and/or telephonic support.
|
High-Tech
n=502 Participants
Delivered via a remote care management platform and digital health tools. Remote care support interactions to occur for at least a four-month period.
High-Tech: Remote care management and self-directed digital tools.
|
Optimal Discharge Planning
n=236 Participants
Delivered via Health Plan support and resources within 14-30 days of an initial home or telephonic visit.
Optimal Discharge Planning: Transition to other Health Plan disease management programs and/or community resources.
|
|---|---|---|---|
|
Care Satisfaction
Baseline
|
2.96 score on a scale
Standard Deviation 0.98
|
2.86 score on a scale
Standard Deviation 0.94
|
2.96 score on a scale
Standard Deviation 1.00
|
|
Care Satisfaction
3-Month
|
3.02 score on a scale
Standard Deviation 1.00
|
2.99 score on a scale
Standard Deviation 0.99
|
2.97 score on a scale
Standard Deviation 0.97
|
|
Care Satisfaction
6-Month
|
3.03 score on a scale
Standard Deviation 0.98
|
2.97 score on a scale
Standard Deviation 1.01
|
2.93 score on a scale
Standard Deviation 1.00
|
|
Care Satisfaction
12-Month
|
3.05 score on a scale
Standard Deviation 1.01
|
3.03 score on a scale
Standard Deviation 1.01
|
3.00 score on a scale
Standard Deviation 0.99
|
SECONDARY outcome
Timeframe: Assessed at baseline, 6- and 12-Months.Population: For each timepoint, participants who were eligible for Medicaid/Medicaid-Medicare with available claims data during at least 9 months (non-continuous) of the past 12 months.
Emergent care use will be measured using existing behavioral and physical health claims data to determine the frequency of emergency department visits within 12-months from enrollment.
Outcome measures
| Measure |
High-Touch
n=551 Participants
Delivered primarily via face-to-face interactions, with telephonic interactions and information sharing that does not require access to mobile devices or the Internet. In-person support and/or telephonic interactions to occur at least four times over at least a four-month period.
High-Touch: Intensive, in-person and/or telephonic support.
|
High-Tech
n=535 Participants
Delivered via a remote care management platform and digital health tools. Remote care support interactions to occur for at least a four-month period.
High-Tech: Remote care management and self-directed digital tools.
|
Optimal Discharge Planning
n=274 Participants
Delivered via Health Plan support and resources within 14-30 days of an initial home or telephonic visit.
Optimal Discharge Planning: Transition to other Health Plan disease management programs and/or community resources.
|
|---|---|---|---|
|
Emergent Care Use
12-Month
|
2.41 visits
Standard Deviation 3.58
|
2.40 visits
Standard Deviation 4.32
|
2.29 visits
Standard Deviation 3.29
|
|
Emergent Care Use
Baseline
|
2.83 visits
Standard Deviation 3.25
|
2.40 visits
Standard Deviation 3.36
|
2.39 visits
Standard Deviation 3.73
|
|
Emergent Care Use
6-Month
|
1.33 visits
Standard Deviation 2.08
|
1.31 visits
Standard Deviation 2.44
|
1.25 visits
Standard Deviation 2.02
|
SECONDARY outcome
Timeframe: Assessed at baseline, 6- and 12-Months.Population: For each timepoint, participants who were eligible for Medicaid/Medicaid-Medicare with available claims data during at least 9 months (non-continuous) of the past 12 months.
Engagement in primary care will be measured using existing behavioral and physical health claims determining participant frequency of non-acute visits for participants in the 12 months following enrollment. Because clinical standards of care are 1 primary care (PCP) visit every 12 months, PCP visits are assessed as a Y/N variable at 12-Months.
Outcome measures
| Measure |
High-Touch
n=559 Participants
Delivered primarily via face-to-face interactions, with telephonic interactions and information sharing that does not require access to mobile devices or the Internet. In-person support and/or telephonic interactions to occur at least four times over at least a four-month period.
High-Touch: Intensive, in-person and/or telephonic support.
|
High-Tech
n=545 Participants
Delivered via a remote care management platform and digital health tools. Remote care support interactions to occur for at least a four-month period.
High-Tech: Remote care management and self-directed digital tools.
|
Optimal Discharge Planning
n=283 Participants
Delivered via Health Plan support and resources within 14-30 days of an initial home or telephonic visit.
Optimal Discharge Planning: Transition to other Health Plan disease management programs and/or community resources.
|
|---|---|---|---|
|
Engagement in Primary Care
Baseline · At least one PCP visit
|
451 Participants
|
468 Participants
|
224 Participants
|
|
Engagement in Primary Care
Baseline · No PCP visit
|
64 Participants
|
41 Participants
|
30 Participants
|
|
Engagement in Primary Care
Baseline · Missing Data
|
44 Participants
|
36 Participants
|
29 Participants
|
|
Engagement in Primary Care
6-Months · At least one PCP visit
|
467 Participants
|
463 Participants
|
242 Participants
|
|
Engagement in Primary Care
6-Months · No PCP visit
|
84 Participants
|
72 Participants
|
32 Participants
|
|
Engagement in Primary Care
6-Months · Missing Data
|
8 Participants
|
10 Participants
|
9 Participants
|
|
Engagement in Primary Care
12-Months · At least one PCP visit
|
467 Participants
|
476 Participants
|
238 Participants
|
|
Engagement in Primary Care
12-Months · No PCP visit
|
62 Participants
|
44 Participants
|
22 Participants
|
|
Engagement in Primary Care
12-Months · Missing Data
|
30 Participants
|
25 Participants
|
23 Participants
|
SECONDARY outcome
Timeframe: Assessed at baseline, 6- and 12-Months.Population: For each timepoint, participants who were eligible for Medicaid/Medicaid-Medicare with available claims data during at least 9 months (non-continuous) of the past 12 months.
Engagement in specialty care will be measured using existing behavioral and physical health claims data determining participant frequency of specialty provider visits for participants in the 12 months following enrollment. Specialty care is inclusive of any care provided outside of primary care, physical therapy, or occupational therapy.
Outcome measures
| Measure |
High-Touch
n=551 Participants
Delivered primarily via face-to-face interactions, with telephonic interactions and information sharing that does not require access to mobile devices or the Internet. In-person support and/or telephonic interactions to occur at least four times over at least a four-month period.
High-Touch: Intensive, in-person and/or telephonic support.
|
High-Tech
n=535 Participants
Delivered via a remote care management platform and digital health tools. Remote care support interactions to occur for at least a four-month period.
High-Tech: Remote care management and self-directed digital tools.
|
Optimal Discharge Planning
n=274 Participants
Delivered via Health Plan support and resources within 14-30 days of an initial home or telephonic visit.
Optimal Discharge Planning: Transition to other Health Plan disease management programs and/or community resources.
|
|---|---|---|---|
|
Engagement in Specialty Care
Baseline
|
7.29 visits
Standard Deviation 10.20
|
7.54 visits
Standard Deviation 8.89
|
7.20 visits
Standard Deviation 8.50
|
|
Engagement in Specialty Care
6-Month
|
4.15 visits
Standard Deviation 5.34
|
4.51 visits
Standard Deviation 6.53
|
4.08 visits
Standard Deviation 5.16
|
|
Engagement in Specialty Care
12-Month
|
7.80 visits
Standard Deviation 9.02
|
8.31 visits
Standard Deviation 10.39
|
7.84 visits
Standard Deviation 9.33
|
SECONDARY outcome
Timeframe: Assessed at baseline, 6- and 12-Months.Population: For each timepoint, participants who were eligible for Medicaid/Medicaid-Medicare with available claims data during at least 9 months (non-continuous) of the past 12 months.
Readmissions over 12 months will be measured using an all-cause readmission rate from inpatient claims for physical and behavioral health service use within one year following discharge from the qualifying inpatient admission prior to enrollment in the study. Inpatient readmissions were lower than hypothesized for the population. As such, we assessed a Y/N variable for inpatient readmissions at 12-Months.
Outcome measures
| Measure |
High-Touch
n=559 Participants
Delivered primarily via face-to-face interactions, with telephonic interactions and information sharing that does not require access to mobile devices or the Internet. In-person support and/or telephonic interactions to occur at least four times over at least a four-month period.
High-Touch: Intensive, in-person and/or telephonic support.
|
High-Tech
n=545 Participants
Delivered via a remote care management platform and digital health tools. Remote care support interactions to occur for at least a four-month period.
High-Tech: Remote care management and self-directed digital tools.
|
Optimal Discharge Planning
n=283 Participants
Delivered via Health Plan support and resources within 14-30 days of an initial home or telephonic visit.
Optimal Discharge Planning: Transition to other Health Plan disease management programs and/or community resources.
|
|---|---|---|---|
|
Inpatient Readmissions Over 12-Months
Baseline · No inpatient admission
|
342 Participants
|
344 Participants
|
170 Participants
|
|
Inpatient Readmissions Over 12-Months
Baseline · One or more inpatient admissions
|
173 Participants
|
165 Participants
|
84 Participants
|
|
Inpatient Readmissions Over 12-Months
Baseline · Missing Data
|
44 Participants
|
36 Participants
|
29 Participants
|
|
Inpatient Readmissions Over 12-Months
6-Month · No inpatient admission
|
412 Participants
|
400 Participants
|
201 Participants
|
|
Inpatient Readmissions Over 12-Months
6-Month · One or more inpatient admissions
|
139 Participants
|
135 Participants
|
73 Participants
|
|
Inpatient Readmissions Over 12-Months
6-Month · Missing Data
|
8 Participants
|
10 Participants
|
9 Participants
|
|
Inpatient Readmissions Over 12-Months
12-Month · No inpatient admission
|
337 Participants
|
332 Participants
|
170 Participants
|
|
Inpatient Readmissions Over 12-Months
12-Month · One or more inpatient admissions
|
192 Participants
|
188 Participants
|
90 Participants
|
|
Inpatient Readmissions Over 12-Months
12-Month · Missing Data
|
30 Participants
|
25 Participants
|
23 Participants
|
SECONDARY outcome
Timeframe: Assessed at baseline, 6- and 12-Months.Population: For each timepoint, participants who were eligible for Medicaid/Medicaid-Medicare with available claims data during at least 9 months (non-continuous) of the past 12 months.
Assessed using existing behavioral health claims data determining frequency of mental health care visits for participants in the 12 months following enrollment. Because of the low frequency, we assess mental health care visits as a Y/N variable.
Outcome measures
| Measure |
High-Touch
n=559 Participants
Delivered primarily via face-to-face interactions, with telephonic interactions and information sharing that does not require access to mobile devices or the Internet. In-person support and/or telephonic interactions to occur at least four times over at least a four-month period.
High-Touch: Intensive, in-person and/or telephonic support.
|
High-Tech
n=545 Participants
Delivered via a remote care management platform and digital health tools. Remote care support interactions to occur for at least a four-month period.
High-Tech: Remote care management and self-directed digital tools.
|
Optimal Discharge Planning
n=283 Participants
Delivered via Health Plan support and resources within 14-30 days of an initial home or telephonic visit.
Optimal Discharge Planning: Transition to other Health Plan disease management programs and/or community resources.
|
|---|---|---|---|
|
Mental Health Care Visits
6-Months · Missing Data
|
8 Participants
|
10 Participants
|
9 Participants
|
|
Mental Health Care Visits
12-Months · No mental health care visits
|
492 Participants
|
484 Participants
|
238 Participants
|
|
Mental Health Care Visits
Baseline · No mental health care visits
|
479 Participants
|
476 Participants
|
237 Participants
|
|
Mental Health Care Visits
Baseline · At least one mental health care visit
|
36 Participants
|
33 Participants
|
17 Participants
|
|
Mental Health Care Visits
Baseline · Missing Data
|
44 Participants
|
36 Participants
|
29 Participants
|
|
Mental Health Care Visits
6-Months · No mental health care visits
|
527 Participants
|
506 Participants
|
256 Participants
|
|
Mental Health Care Visits
6-Months · At least one mental health care visit
|
24 Participants
|
29 Participants
|
18 Participants
|
|
Mental Health Care Visits
12-Months · At least one mental health care visit
|
37 Participants
|
36 Participants
|
22 Participants
|
|
Mental Health Care Visits
12-Months · Missing Data
|
30 Participants
|
25 Participants
|
23 Participants
|
SECONDARY outcome
Timeframe: Assessed at baseline, 6- and 12-MonthsPopulation: Only a very small portion of our total sample size was eligible for Gaps in Care analyses.
Gaps in care will be assessed using Healthcare Effectiveness Data and Information Set (HEDIS) quality metrics. For asthma, we assess the percentage of members 21-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. Two rates are reported: 1. The percentage of members who remained on an asthma controller medication for at least 50% of their treatment period (MMA-1a). 2. The percentage of members who remained on an asthma controller medication for at least 75% of their treatment period (MMA-1b).
Outcome measures
| Measure |
High-Touch
n=8 Participants
Delivered primarily via face-to-face interactions, with telephonic interactions and information sharing that does not require access to mobile devices or the Internet. In-person support and/or telephonic interactions to occur at least four times over at least a four-month period.
High-Touch: Intensive, in-person and/or telephonic support.
|
High-Tech
n=13 Participants
Delivered via a remote care management platform and digital health tools. Remote care support interactions to occur for at least a four-month period.
High-Tech: Remote care management and self-directed digital tools.
|
Optimal Discharge Planning
n=6 Participants
Delivered via Health Plan support and resources within 14-30 days of an initial home or telephonic visit.
Optimal Discharge Planning: Transition to other Health Plan disease management programs and/or community resources.
|
|---|---|---|---|
|
Gaps in Care: Asthma
6-Month MMA-1b (75%) · Closed gap in care
|
2 Participants
|
7 Participants
|
2 Participants
|
|
Gaps in Care: Asthma
12-Month MMA-1b (75%) · Did not close gap in care
|
1 Participants
|
4 Participants
|
0 Participants
|
|
Gaps in Care: Asthma
12-Month MMA-1b (75%) · Closed gap in care
|
5 Participants
|
3 Participants
|
2 Participants
|
|
Gaps in Care: Asthma
Baseline MMA-1a (50%) · Did not close gap in care
|
6 Participants
|
3 Participants
|
3 Participants
|
|
Gaps in Care: Asthma
Baseline MMA-1a (50%) · Closed gap in care
|
2 Participants
|
10 Participants
|
3 Participants
|
|
Gaps in Care: Asthma
6-Month MMA-1a (50%) · Did not close gap in care
|
2 Participants
|
3 Participants
|
1 Participants
|
|
Gaps in Care: Asthma
6-Month MMA-1a (50%) · Closed gap in care
|
2 Participants
|
8 Participants
|
2 Participants
|
|
Gaps in Care: Asthma
12-Month MMA-1a (50%) · Did not close gap in care
|
1 Participants
|
1 Participants
|
0 Participants
|
|
Gaps in Care: Asthma
12-Month MMA-1a (50%) · Closed gap in care
|
5 Participants
|
6 Participants
|
2 Participants
|
|
Gaps in Care: Asthma
Baseline MMA-1b (75%) · Closed gap in care
|
2 Participants
|
4 Participants
|
3 Participants
|
|
Gaps in Care: Asthma
Baseline MMA-1b (75%) · Did not close gap in care
|
6 Participants
|
9 Participants
|
3 Participants
|
|
Gaps in Care: Asthma
6-Month MMA-1b (75%) · Did not close gap in care
|
2 Participants
|
4 Participants
|
1 Participants
|
SECONDARY outcome
Timeframe: Assessed at baseline, 6- and 12-MonthsPopulation: Only a very small portion of the total sample was eligible for COPD Gaps in Care analyses.
Gaps in care will be assessed using Healthcare Effectiveness Data and Information Set (HEDIS) quality metrics. For COPD, we assess the percentage of COPD exacerbations for members 40 years of age and older who had an acute inpatient discharge or ED encounter and who were dispensed appropriate medications. Two rates reported: 1. Dispensed a systemic corticosteroid within 14 days of the event (PCE-1) 2. Dispensed a bronchodilator within 30 days of the event (PCE-2)
Outcome measures
| Measure |
High-Touch
n=57 Participants
Delivered primarily via face-to-face interactions, with telephonic interactions and information sharing that does not require access to mobile devices or the Internet. In-person support and/or telephonic interactions to occur at least four times over at least a four-month period.
High-Touch: Intensive, in-person and/or telephonic support.
|
High-Tech
n=54 Participants
Delivered via a remote care management platform and digital health tools. Remote care support interactions to occur for at least a four-month period.
High-Tech: Remote care management and self-directed digital tools.
|
Optimal Discharge Planning
n=23 Participants
Delivered via Health Plan support and resources within 14-30 days of an initial home or telephonic visit.
Optimal Discharge Planning: Transition to other Health Plan disease management programs and/or community resources.
|
|---|---|---|---|
|
Gaps in Care: Chronic Obstructive Pulmonary Disease (COPD)
Baseline PCE-1 · Did not close gap in care
|
4 Participants
|
3 Participants
|
1 Participants
|
|
Gaps in Care: Chronic Obstructive Pulmonary Disease (COPD)
Baseline PCE-1 · Closed gap in care
|
20 Participants
|
25 Participants
|
14 Participants
|
|
Gaps in Care: Chronic Obstructive Pulmonary Disease (COPD)
6-Month PCE-1 · Did not close gap in care
|
8 Participants
|
2 Participants
|
1 Participants
|
|
Gaps in Care: Chronic Obstructive Pulmonary Disease (COPD)
12-Month PCE-1 · Did not close gap in care
|
2 Participants
|
1 Participants
|
3 Participants
|
|
Gaps in Care: Chronic Obstructive Pulmonary Disease (COPD)
12-Month PCE-1 · Closed gap in care
|
33 Participants
|
33 Participants
|
11 Participants
|
|
Gaps in Care: Chronic Obstructive Pulmonary Disease (COPD)
Baseline PCE-2 · Did not close gap in care
|
8 Participants
|
4 Participants
|
3 Participants
|
|
Gaps in Care: Chronic Obstructive Pulmonary Disease (COPD)
Baseline PCE-2 · Closed gap in care
|
16 Participants
|
24 Participants
|
12 Participants
|
|
Gaps in Care: Chronic Obstructive Pulmonary Disease (COPD)
6-Month PCE-2 · Closed gap in care
|
50 Participants
|
46 Participants
|
20 Participants
|
|
Gaps in Care: Chronic Obstructive Pulmonary Disease (COPD)
12-Month PCE-2 · Did not close gap in care
|
5 Participants
|
7 Participants
|
1 Participants
|
|
Gaps in Care: Chronic Obstructive Pulmonary Disease (COPD)
12-Month PCE-2 · Closed gap in care
|
30 Participants
|
27 Participants
|
13 Participants
|
|
Gaps in Care: Chronic Obstructive Pulmonary Disease (COPD)
6-Month PCE-1 · Closed gap in care
|
49 Participants
|
52 Participants
|
22 Participants
|
|
Gaps in Care: Chronic Obstructive Pulmonary Disease (COPD)
6-Month PCE-2 · Did not close gap in care
|
7 Participants
|
8 Participants
|
3 Participants
|
SECONDARY outcome
Timeframe: Assessed at 30-days from an index admission discharge.Population: Only a small portion of the total sample was eligible for CHF Gaps in Care analyses.
For Gaps in care related to CHF, we assess readmission rate within 30 days after discharge from inpatient stay for members with a diagnosis of CHF prior index hospitalization.
Outcome measures
| Measure |
High-Touch
n=84 Participants
Delivered primarily via face-to-face interactions, with telephonic interactions and information sharing that does not require access to mobile devices or the Internet. In-person support and/or telephonic interactions to occur at least four times over at least a four-month period.
High-Touch: Intensive, in-person and/or telephonic support.
|
High-Tech
n=98 Participants
Delivered via a remote care management platform and digital health tools. Remote care support interactions to occur for at least a four-month period.
High-Tech: Remote care management and self-directed digital tools.
|
Optimal Discharge Planning
n=39 Participants
Delivered via Health Plan support and resources within 14-30 days of an initial home or telephonic visit.
Optimal Discharge Planning: Transition to other Health Plan disease management programs and/or community resources.
|
|---|---|---|---|
|
Gaps in Care: Congestive Heart Failure (CHF)
Baseline
|
0.04 Number of readmissions within 30 days
Standard Deviation 0.17
|
0.04 Number of readmissions within 30 days
Standard Deviation 0.17
|
0.02 Number of readmissions within 30 days
Standard Deviation 0.11
|
|
Gaps in Care: Congestive Heart Failure (CHF)
6-Month
|
0.02 Number of readmissions within 30 days
Standard Deviation 0.10
|
0.04 Number of readmissions within 30 days
Standard Deviation 0.15
|
0.03 Number of readmissions within 30 days
Standard Deviation 0.12
|
|
Gaps in Care: Congestive Heart Failure (CHF)
12-Month
|
0.04 Number of readmissions within 30 days
Standard Deviation 0.13
|
0.04 Number of readmissions within 30 days
Standard Deviation 0.13
|
0.04 Number of readmissions within 30 days
Standard Deviation 0.12
|
SECONDARY outcome
Timeframe: Assessed at baseline, 6- and 12-MonthsPopulation: Only a very small portion of the total sample was eligible for CVD Gaps in Care analyses.
Gaps in care will be assessed using Healthcare Effectiveness Data and Information Set (HEDIS) quality metrics. For CVD, we assess the percentage of males 21-75 years of age and females 40-75 years of age during the measurement year, who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and met the following criteria. The following rates are reported: 1. Received Statin Therapy. Members who were dispensed at least one high-intensity or moderate-intensity statin medication during the measurement year (SPC-1). 2. Statin Adherence 80%. Members who remained on a high-intensity or moderate-intensity statin medication for at least 80% of the treatment period (SPC-2).
Outcome measures
| Measure |
High-Touch
n=59 Participants
Delivered primarily via face-to-face interactions, with telephonic interactions and information sharing that does not require access to mobile devices or the Internet. In-person support and/or telephonic interactions to occur at least four times over at least a four-month period.
High-Touch: Intensive, in-person and/or telephonic support.
|
High-Tech
n=79 Participants
Delivered via a remote care management platform and digital health tools. Remote care support interactions to occur for at least a four-month period.
High-Tech: Remote care management and self-directed digital tools.
|
Optimal Discharge Planning
n=40 Participants
Delivered via Health Plan support and resources within 14-30 days of an initial home or telephonic visit.
Optimal Discharge Planning: Transition to other Health Plan disease management programs and/or community resources.
|
|---|---|---|---|
|
Gaps in Care: Cardiovascular Disease (CVD)
Baseline SPC-1 · Did not close gap in care
|
7 Participants
|
4 Participants
|
5 Participants
|
|
Gaps in Care: Cardiovascular Disease (CVD)
6-Month SPC-1 · Did not close gap in care
|
8 Participants
|
5 Participants
|
6 Participants
|
|
Gaps in Care: Cardiovascular Disease (CVD)
6-Month SPC-1 · Closed gap in care
|
42 Participants
|
49 Participants
|
26 Participants
|
|
Gaps in Care: Cardiovascular Disease (CVD)
Baseline SPC-2 · Did not close gap in care
|
16 Participants
|
6 Participants
|
7 Participants
|
|
Gaps in Care: Cardiovascular Disease (CVD)
Baseline SPC-2 · Closed gap in care
|
22 Participants
|
32 Participants
|
15 Participants
|
|
Gaps in Care: Cardiovascular Disease (CVD)
6-Month SPC-2 · Did not close gap in care
|
11 Participants
|
17 Participants
|
11 Participants
|
|
Gaps in Care: Cardiovascular Disease (CVD)
Baseline SPC-1 · Closed gap in care
|
38 Participants
|
38 Participants
|
22 Participants
|
|
Gaps in Care: Cardiovascular Disease (CVD)
12-Month SPC-1 · Did not close gap in care
|
11 Participants
|
10 Participants
|
7 Participants
|
|
Gaps in Care: Cardiovascular Disease (CVD)
12-Month SPC-1 · Closed gap in care
|
48 Participants
|
69 Participants
|
33 Participants
|
|
Gaps in Care: Cardiovascular Disease (CVD)
6-Month SPC-2 · Closed gap in care
|
31 Participants
|
32 Participants
|
15 Participants
|
|
Gaps in Care: Cardiovascular Disease (CVD)
12-Month SPC-2 · Did not close gap in care
|
14 Participants
|
23 Participants
|
14 Participants
|
|
Gaps in Care: Cardiovascular Disease (CVD)
12-Month SPC-2 · Closed gap in care
|
34 Participants
|
46 Participants
|
19 Participants
|
SECONDARY outcome
Timeframe: Assessed at baseline, 6- and 12-MonthsPopulation: Only a very small portion of the total sample was eligible for Diabetes Gaps in Care analyses.
Gaps in care will be assessed using Healthcare Effectiveness Data and Information Set (HEDIS) quality metrics. For diabetes, we assess the percentage of members 40-75 years of age during the measurement year with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) who met the following criteria. Two rates are reported: 1. Received Statin Therapy. Members who were dispensed at least one statin medication of any intensity during the measurement year (SPD-1). 2. Statin Adherence 80%. Members who remained on a statin medication of any intensity for at least 80% of the treatment period (SPD-2).
Outcome measures
| Measure |
High-Touch
n=107 Participants
Delivered primarily via face-to-face interactions, with telephonic interactions and information sharing that does not require access to mobile devices or the Internet. In-person support and/or telephonic interactions to occur at least four times over at least a four-month period.
High-Touch: Intensive, in-person and/or telephonic support.
|
High-Tech
n=119 Participants
Delivered via a remote care management platform and digital health tools. Remote care support interactions to occur for at least a four-month period.
High-Tech: Remote care management and self-directed digital tools.
|
Optimal Discharge Planning
n=59 Participants
Delivered via Health Plan support and resources within 14-30 days of an initial home or telephonic visit.
Optimal Discharge Planning: Transition to other Health Plan disease management programs and/or community resources.
|
|---|---|---|---|
|
Gaps in Care: Diabetes
6-Month SPD-1 · Did not close gap in care
|
28 Participants
|
25 Participants
|
12 Participants
|
|
Gaps in Care: Diabetes
12-Month SPD-1 · Did not close gap in care
|
20 Participants
|
19 Participants
|
9 Participants
|
|
Gaps in Care: Diabetes
12-Month SPD-1 · Closed gap in care
|
68 Participants
|
69 Participants
|
25 Participants
|
|
Gaps in Care: Diabetes
Baseline SPD-2 · Did not close gap in care
|
19 Participants
|
31 Participants
|
18 Participants
|
|
Gaps in Care: Diabetes
6-Month SPD-2 · Did not close gap in care
|
18 Participants
|
27 Participants
|
11 Participants
|
|
Gaps in Care: Diabetes
Baseline SPD-1 · Did not close gap in care
|
25 Participants
|
24 Participants
|
15 Participants
|
|
Gaps in Care: Diabetes
Baseline SPD-1 · Closed gap in care
|
80 Participants
|
95 Participants
|
44 Participants
|
|
Gaps in Care: Diabetes
6-Month SPD-1 · Closed gap in care
|
79 Participants
|
79 Participants
|
33 Participants
|
|
Gaps in Care: Diabetes
Baseline SPD-2 · Closed gap in care
|
61 Participants
|
64 Participants
|
26 Participants
|
|
Gaps in Care: Diabetes
6-Month SPD-2 · Closed gap in care
|
61 Participants
|
52 Participants
|
22 Participants
|
|
Gaps in Care: Diabetes
12-Month SPD-2 · Did not close gap in care
|
14 Participants
|
26 Participants
|
6 Participants
|
|
Gaps in Care: Diabetes
12-Month SPD-2 · Closed gap in care
|
54 Participants
|
43 Participants
|
19 Participants
|
SECONDARY outcome
Timeframe: Assessed at baseline, 6- and 12-MonthsPopulation: Only a very small portion of the total sample was eligible for Depression Gaps in Care analyses.
Gaps in care will be assessed using Healthcare Effectiveness Data and Information Set (HEDIS) quality metrics. For depression, we assess the percentage of members diagnosed with a new episode of major depression, treated with antidepressant medication, and who remained on an antidepressant medication for: 1. Effective Acute Phase Treatment - 84 days of continuous treatment during 114-day period following the Index Prescription Start Date (AMM-1). 2. Effective Continuation Phase Treatment - 180 days of continuous treatment during 231-day period following the Index Prescription Start Date (AMM-2).
Outcome measures
| Measure |
High-Touch
n=56 Participants
Delivered primarily via face-to-face interactions, with telephonic interactions and information sharing that does not require access to mobile devices or the Internet. In-person support and/or telephonic interactions to occur at least four times over at least a four-month period.
High-Touch: Intensive, in-person and/or telephonic support.
|
High-Tech
n=59 Participants
Delivered via a remote care management platform and digital health tools. Remote care support interactions to occur for at least a four-month period.
High-Tech: Remote care management and self-directed digital tools.
|
Optimal Discharge Planning
n=34 Participants
Delivered via Health Plan support and resources within 14-30 days of an initial home or telephonic visit.
Optimal Discharge Planning: Transition to other Health Plan disease management programs and/or community resources.
|
|---|---|---|---|
|
Gaps in Care: Depression
12-Month AMM-1 · Closed gap in care
|
34 Participants
|
37 Participants
|
25 Participants
|
|
Gaps in Care: Depression
Baseline AMM-1 · Closed gap in care
|
29 Participants
|
35 Participants
|
13 Participants
|
|
Gaps in Care: Depression
6-Month AMM-1 · Did not close gap in care
|
20 Participants
|
14 Participants
|
6 Participants
|
|
Gaps in Care: Depression
6-Month AMM-1 · Closed gap in care
|
35 Participants
|
30 Participants
|
19 Participants
|
|
Gaps in Care: Depression
Baseline AMM-2 · Did not close gap in care
|
28 Participants
|
19 Participants
|
16 Participants
|
|
Gaps in Care: Depression
12-Month AMM-2 · Did not close gap in care
|
32 Participants
|
31 Participants
|
14 Participants
|
|
Gaps in Care: Depression
12-Month AMM-2 · Closed gap in care
|
24 Participants
|
28 Participants
|
20 Participants
|
|
Gaps in Care: Depression
Baseline AMM-1 · Did not close gap in care
|
24 Participants
|
12 Participants
|
10 Participants
|
|
Gaps in Care: Depression
12-Month AMM-1 · Did not close gap in care
|
22 Participants
|
22 Participants
|
9 Participants
|
|
Gaps in Care: Depression
Baseline AMM-2 · Closed gap in care
|
25 Participants
|
28 Participants
|
7 Participants
|
|
Gaps in Care: Depression
6-Month AMM-2 · Did not close gap in care
|
26 Participants
|
24 Participants
|
9 Participants
|
|
Gaps in Care: Depression
6-Month AMM-2 · Closed gap in care
|
29 Participants
|
20 Participants
|
16 Participants
|
Adverse Events
High-Touch
High-Tech
Optimal Discharge Planning
Serious adverse events
Adverse event data not reported
Other adverse events
Adverse event data not reported
Additional Information
Kelly Williams, PhD, MPH
UPMC Center for High-Value Health Care
Results disclosure agreements
- Principal investigator is a sponsor employee
- Publication restrictions are in place