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OpenTrials
Completed

NCT Number: NCT02106221

Transforming Outcomes for Patients Through Medical Home Evaluation & reDesign

The purpose of this study is to support enhancement, implementation, and evaluation of an improved model for delivering improved primary care to high-risk older adults through the use of health IT tools, focusing on issues related to the patient-centered primary care home (PCPCH) and other similar high-value elements that are proposed to improve patient outcomes. During this study, participating clinics will utilize the already-implemented Integrated Care Coordination Information System (ICCIS). Clinic staff will meet with a practice facilitator (monthly and as needed), and will track study activities and submit invoices via ICCIS reporting. These invoices will be used to simulate a shared savings model where clinics will be reimbursed based on their progress and effort towards their goals.

Clinics will set and work towards goals that they have chosen. Goals for the control arm are self-selected by the clinics themselves; goals for the invention arm are related to high-value elements (HVE) that have been identified as areas that can improve patient outcomes. These HVE are:

1. Evidence-based Care Management Based on Need 2. Identification of At-Risk Populations 3. Patient Engagement and Alerts Based on Goals 4. Integrated Information for Care Management, especially around Utilization 5. Population Management Tools

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Key information

Conditions

Nurse Based Care Management Health Information Technology

Age range

18 year and older

Sex eligibility

All sexes

Study type

Interventional

Phase

Phase 3

Primary location

Oregon Health & Science University

Portland, Oregon, 97239, United States

Who can participate

Healthy volunteers accepted: No

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

Inclusion criteria

  • clinics must be from the Oregon Rural Practice-based Research Network (ORPRN)
  • Primary care clinic meeting one of the following health care setting descriptions: 1) small clinics in rural area, 2) medium-sized clinics in rural area, 3) clinics in moderate-sized health system, or 4) clinic within an academic medical center;
  • Clinic will or has attested for PCPCH, achieving Tier 2 or 3 (of 3 tiers);
  • Clinic is willing to contract to be a PCPCH with payers;
  • Clinic has stable electronic health record (EHR) system with no plans to change systems during study duration;
  • Clinic has willingness to receive practice facilitation and participate in study activities, including completion of assessments;
  • Clinic has willingness to engage with research team members as defined in the study.

Exclusion criteria

  • patients less then 18

Treatment and study plan

Intervention

Other

Will receive payments based on achievement in meeting goals based on specified high value elements as well as effort.

Control

Other

Will receive payments based on achievement in meeting goals.

Primary outcomes

  1. Preventable utilization

    Time frame: 12 months

    Reduce by 15% ED visits and hospitalizations related to ambulatory care

  2. Quality Measures Improvement

    Time frame: 12 months

    Select 3 standard measures related to the patient population and improve each by 20%. (An example of such a measure might be fall risk assessment. There are several quality measures that are included as part of the HIT tool that is provided to clinics.)

  3. Patient Satisfaction

    Time frame: 12 months

    Improve patient experience with clinic and satisfaction with care coordination by 10% Patient satisfaction will be determined by a CAHPS patient satisfaction survey that is sent out at the start and end of the study.

Sponsors and collaborators

Lead sponsor

Care Management Plus

Other

Collaborators

  • Gordon and Betty Moore Foundation

Registry information

Acronym: TOPMED

Important dates

Study start
2011
Primary completion
2014
Study completion
2015
First posted
Apr 8, 2014
Registry last updated
Jul 29, 2015

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.

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