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OpenTrials
Completed

NCT Number: NCT02411409

Impact of the CommunityRx Program on Health, Service Utilization and Costs

The CommunityRx system generates patient-centered e-prescriptions for community services (HealtheRx) via an interface between the electronic health records (EHR) and a comprehensive community resource database. Based on a patient's diagnoses, a HealtheRx will be printed automatically at the end of the ambulatory care visit and will provide patients with a customized map and/or list of places in their community that provide health and social services as well as contact information for a local community health worker who can provide limited case management support. The CommunityRx program aims to promote: 1) better healthcare, 2) better health, and 3) lower cost. The purpose of this research is to systematically evaluate the impact of CommunityRx on health outcomes as well as health care service utilization and total cost of care for Medicaid, Medicare and other beneficiaries. The investigators hypothesize that beneficiaries who participate in the CommunityRx intervention will experience better healthcare, better health and lower total cost of care.

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Key information

Conditions

Connecting Patients to Self-care Resources

Sex eligibility

All sexes

Study type

Interventional

Phase

Not applicable

Primary location

University of Chicago

Chicago, Illinois, 60637, United States

Who can participate

Healthy volunteers accepted: Yes

Only the study team can determine whether someone qualifies for participation.

Inclusion criteria

  • Intervention group eligibility: Patients receiving ambulatory care at a clinical site connected to CommunityRx who live in the CommunityRx geography. Control group eligibility: Patients receiving care at a clinical site connected to CommunityRx who live outside the CommunityRx geography.

Exclusion criteria

  • Patients receiving care at a clinical site not connected to CommunityRx.

Treatment and study plan

HealtheRx

Behavioral

The HealtheRx is a prescription for community self-care resources. It includes a printed list of self-care resources provided to the patient at an ambulatory visit and tailored based on data from the electronic medical record.

Primary outcomes

  1. Change in cost per beneficiary per year

    Time frame: Annual, up to 6 years

    Cost per beneficiary per year

Secondary outcomes

  1. Change in emergency department visit rate

    Time frame: Every 3 months, up to 72 months

    Hospital emergency department visit rate, overall and for patients diagnosed with a) diabetes, b) hypertension, and c) asthma

  2. Change in HbA1c control

    Time frame: Every 3 months, up to 72 months

    Percentage of patients 18-75 years of age with diabetes (type 1 or type 2) who had hemoglobin A1c > 9.0 %.

  3. Change in controlling high blood pressure

    Time frame: Every 3 months, up to 72 months

    % of patients >=18 years old with hypertension diagnosis and a most recent BP measure <140/90mg

  4. Change in body mass index

    Time frame: Every 3 months, up to 72 months

    Percentage of patients overweight or obese (BMI >=25.0 and <30, BMI >=30)

  5. Change in inpatient admission rate

    Time frame: Every 3 months, up to 72 months

    Average number of in patient admissions per person

  6. Change in participant satisfaction (percentage of participants reporting they are satisfied with the HealtheRx)

    Time frame: Every 3 months, up to 60 months

    Program participant satisfaction survey, percentage of participants reporting they are satisfied with the HealtheRx

  7. Change in provider satisfaction ( percent of providers reporting they are satisfied with the HealtheRx system)

    Time frame: Every 6 months, up to 60 months

    Provider satisfaction survey, percent of providers reporting they are satisfied with the HealtheRx system

  8. Change in rate of participant use of community-based service providers listed on HealtheRx

    Time frame: Every 3 months, up to 60 months

    Program participant survey, percent of participants who report using at least 1 service listed on their HealtheRx

  9. Change in HealtheRx reach (proportion of the population in the geography who receive at least 1 HealtheRx)

    Time frame: Every 3 months, up to 60 months

    The proportion of the population in the geography who receive at least 1 HealtheRx

  10. Change in HealtheRx delivery (providers communicate to patients about the HealtheRx)

    Time frame: Every 3 months, up to 60 months

    providers communicate to patients about the HealtheRx

  11. Change in HealtheRx usefulness (participant survey, the percent of program participants who report that their HealtheRx is useful)

    Time frame: Every 3 months, up to 60 months

    Program participant survey, the percent of program participants who report that their HealtheRx is useful

  12. Change in HealtheRx Understandability (participant survey, the percent of program participants who report that their HealtheRx is easy to understand)

    Time frame: Every 3 months, up to 60 months

    Program participant survey, the percent of program participants who report that their HealtheRx is easy to understand

  13. Change in information sharing (participant survey, the percent of program participants who report that they shared information about the HealtheRx with someone else)

    Time frame: Every 3 months, up to 60 months

    Program participant survey, the percent of program participants who report that they shared information about the HealtheRx with someone else

  14. Change in knowledge about resources (participant survey, the percent of program participants who report that they did not know about some of the places listed on their HealtheRx)

    Time frame: Every 3 months, up to 60 months

    Program participant survey, the percent of program participants who report that they did not know about some of the places listed on their HealtheRx

  15. Change in provider confidence in serving social needs (Provider satisfaction survey,)

    Time frame: Every 6 months, up to 60 months

    Provider satisfaction survey, the proportion of providers reporting they are confident in their ability to serve their patients social needs

Other outcomes

  1. Change in technical problems with the CommunityRx system (e.g., number of times system does not work properly)

    Time frame: Every 3 months, up to 60 months

    The number of technical problems experienced with the CommunityRx system (e.g., number of times system does not work properly)

  2. Change in % of eligible patients receiving a HealtheRx

    Time frame: Every 3 months, up to 60 months

    CommunityRx database and electronic medical records, the proportion of eligible patients who receive a HealtheRx

  3. Change in number of places mapped (community organizations, identified in the geographic region)

    Time frame: Every year, up to 6 years

    Number of places, or community organizations, identified in the geographic region

  4. Change in number of CommunityRx reports delivered (Number of CommunityRx reports created and given to community organizations)

    Time frame: Every 3 months, up to 60 months

    Number of CommunityRx reports created and given to community organizations

  5. Change in number of times a community health information specialist is contacted (CHIS call tracker)

    Time frame: Every 3 months, up to 60 months

    CHIS call tracker, number of times a program participant contacted a CHIS

  6. Change in referrals by service type (number of referrals, or number of times a service was listed on a HealtheRx)

    Time frame: Every 3 months, up to 60 months

    CommunityRx database, number of referrals, or number of times a service was listed on a HealtheRx

  7. Change in services identified (number of services identified as available at community organizations0

    Time frame: Every 3 months, up to 60 months

    Service level survey, count of number of services identified as available at community organizations

Sponsors and collaborators

Lead sponsor

University of Chicago

Other

Registry information

Important dates

Study start
2013
Primary completion
2016
Study completion
2023
First posted
Apr 8, 2015
Registry last updated
May 9, 2024

OpenTrials presents study information sourced from ClinicalTrials.gov. The official registry record should be consulted for the latest information.

View the official ClinicalTrials.gov record (opens in a new tab)

This listing is for discovery and informational purposes only. It is not medical advice, does not guarantee that a study is recruiting, and does not determine eligibility. Contact the study team and a qualified healthcare professional when considering participation.