At a glance
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Improving How Older Adults at Risk for Cardiovascular Outcomes Are Selected for Care Coordination
In Brief
A clinical study evaluating Care coordination delivered based on perceived need and Care coordination delivered based on usual care (e.g. discharge from hospital) for Cardiovascular Diseases and 9 related conditions. Completed, enrolled 400 participants across 1 site.
Detailed Summary
This pragmatic clinical trial embedded in an accountable care organization will determine the comparative effectiveness of two approaches for assigning care coordinators to older adults at risk for cardiovascular outcomes. The hypothesis is that assigning care coordinators to older adults based on perceived need will be more effective at preventing emergency department visits and hospitalizations compared to usual care.
Study Details
Timeline
Interventions
If patients in intervention group report on the survey that they experience difficulty coordinating care among their providers, the patient will be selected for care management services. Those services will attempt to address the problems with care coordination that the proxy reported.
If a patient is discharged from a hospital, the patient will be selected for care management services.