Improving How Older Adults at Risk for Cardiovascular Outcomes Are Selected for Care Coordination

This project will use a pragmatic clinical trial embedded in an accountable care organization (ACO) to determine the comparative effectiveness of two different approaches for selecting older adults at risk for cardiovascular outcomes to receive support from care coordinators: (1) an approach that assigns older adults to care coordinators based on self-reported difficulty with care coordination, or (2) usual care, which generally assigns older adults to care coordinators after hospital discharge, regardless of perceived need. The investigators will include community-dwelling Medicare beneficiaries ≥65 years old with cardiovascular disease (CVD) or 1 or more CVD risk factors who have been attributed to the NewYork Quality Care ACO and who have fragmented care. The investigators will randomize the participants into two groups. This study is highly pragmatic, and the intervention is sustainable and scalable. Moreover, the proposed approach has the potential to improve care delivery and outcomes for older adults at risk for cardiovascular outcomes.

Inclusion criteria

• Medicare beneficiaries 65 years and older,
• Attributed to the NewYork Quality Care accountable care organization,
• Are community-dwelling,
• Have cardiovascular disease or 1 or more cardiovascular risk factors, and
• Had highly fragmented ambulatory care in the prior year (defined as a reversed Bice-Boxerman Index greater than or equal to 0.85)

Exclusion criteria

• Those who reside in long-term care or nursing home facilities (based on addresses in Medicare claims)
• Enrolled in home hospice
• Dementia (as measured in claims using the Bynum Standard 1-year definition)