Care Coordination Intervention Research Articles

Cost-benefit Analysis of Physician Assistant-led Care Coordination Intervention in Outpatient Teleneurology (P7-4.004)

Cost-benefit Analysis of Physician Assistant-led Care Coordination Intervention in Outpatient Teleneurology (P7-4.004)

Remote Between Visit Monitoring in Inflammatory Bowel Disease Care: A Qualitative Study of CAPTURE-IBD Participants and Care Team Members.

We recently showed that CAPTURE-inflammatory bowel disease (IBD)-a care coordination intervention comprised of routine remote monitoring of patient-reported outcomes (PRO) and a care coordinator-triggered care pathway-was more effective at reducing symptom burden for patients with IBD compared to usual care. We aimed to understand how patients and care team providers experienced the intervention and evaluate purported mechanisms of action to plan for future implementation. In this study, 205 patients were randomized to CAPTURE-IBD (n = 100) or usual care(n = 105). We conducted semi-structured interviews with 16 of the 100 participants in the CAPTURE-IBD arm and 5 care team providers to achieve thematic saturation. We used qualitative rapid analysis to generate a broad understanding of experiences, perceived impact, the coordinator role, and suggested improvements. Findings highlight that the intervention was acceptable and user-friendly, despite concerns regarding increased nursing workload. Both participants and care team providers perceived the intervention as valuable in supporting symptom monitoring, psychosocial care, and between-visit action plans to improve IBD care and health outcomes. However, few participants leveraged the care coordinator as intended. Finally, participants reported that the intervention could be better tailored to capture day-to-day symptom changes and to meet the needs of patients with specific comorbid conditions (eg, ostomies). Remote PRO monitoring is acceptable and may be valuable in improving care management, promoting tight control, and supporting whole health in IBD. Future efforts should focus on testing and implementing refined versions of CAPTURE-IBD tailored to different clinical settings.

An implementation strategy postmortem method developed in the VA rural Transitions Nurse Program to inform spread and scale-up.

High-quality implementation evaluations report on intervention fidelity and adaptations made, but a practical process for evaluating implementation strategies is needed. A retrospective method for evaluating implementation strategies is also required as prospective methods can be resource intensive. This study aimed to establish an implementation strategy postmortem method to identify the implementation strategies used, when, and their perceived importance. We used the rural Transitions Nurse Program (TNP) as a case study, a national care coordination intervention implemented at 11 hospitals over three years. The postmortem used a retrospective, mixed method, phased approach. Implementation team and front-line staff characterized the implementation strategies used, their timing, frequency, ease of use, and their importance to implementation success. The Expert Recommendations for Implementing Change (ERIC) compilation, the Quality Enhancement Research Initiative phases, and Proctor and colleagues' guidance were used to operationalize the strategies. Survey data were analyzed descriptively, and qualitative data were analyzed using matrix content analysis. The postmortem method identified 45 of 73 ERIC strategies introduced, including 41 during pre-implementation, 37 during implementation, and 27 during sustainment. External facilitation, centralized technical assistance, and clinical supervision were ranked as the most important and frequently used strategies. Implementation strategies were more intensively applied in the beginning of the study and tapered over time. The postmortem method identified that more strategies were used in TNP than planned and identified the most important strategies from the perspective of the implementation team and front-line staff. The findings can inform other implementation studies as well as dissemination of the TNP intervention.

Effectiveness of the acute stroke care map program in reducing in-hospital delay for acute ischemic stroke in a Chinese urban area: an interrupted time series analysis.

Timely intravenous thrombolysis (IVT) is crucial for improving outcomes in acute ischemic stroke (AIS) patients. This study evaluates the effectiveness of the Acute Stroke Care Map (ASCaM) initiative in Shenyang, aimed at reducing door-to-needle times (DNT) and thus improving the timeliness of care for AIS patients. An retrospective cohort study was conducted from April 2019 to December 2021 in 30 hospitals participating in the ASCaM initiative in Shenyang. The ASCaM bundle included strategies such as EMS prenotification, rapid stroke triage, on-call stroke neurologists, immediate neuroimaging interpretation, and the innovative Pre-hospital Emergency Call and Location Identification feature. An interrupted time series analysis (ITSA) was used to assess the impact of ASCaM on DNT, comparing 9 months pre-intervention with 24 months post-intervention. Data from 9,680 IVT-treated ischemic stroke patients were analyzed, including 2,401 in the pre-intervention phase and 7,279 post-intervention. The ITSA revealed a significant reduction in monthly DNT by -1.12 min and a level change of -5.727 min post-ASCaM implementation. The ASCaM initiative significantly reduced in-hospital delays for AIS patients, demonstrating its effectiveness as a comprehensive stroke care improvement strategy in urban settings. These findings highlight the potential of coordinated care interventions to enhance timely access to reperfusion therapies and overall stroke prognosis.

Factors influencing implementation of a care coordination intervention for cancer survivors with multiple comorbidities in a safety-net system: an application of the Implementation Research Logic Model

BackgroundUnder- and uninsured cancer survivors have significant medical, social, and economic complexity. For these survivors, effective care coordination between oncology and primary care teams is critical for high-quality, comprehensive care. While evidence-based interventions exist to improve coordination between healthcare teams, testing implementation of these interventions for cancer survivors seen in real-world safety-net settings has been limited. This study aimed to (1) identify factors influencing implementation of a multicomponent care coordination intervention (nurse coordinator plus patient registry) focused on cancer survivors with multiple comorbidities in an integrated safety-net system and (2) identify mechanisms through which the factors impacted implementation outcomes.MethodsWe conducted semi-structured interviews (patients, providers, and system leaders), structured observations of primary care and oncology operations, and document analysis during intervention implementation between 2016 and 2020. The practice change model (PCM) guided data collection to identify barriers and facilitators of implementation; the PCM, Consolidated Framework for Implementation Research, and Implementation Research Logic Model guided four immersion/crystallization data analysis and synthesis cycles to identify mechanisms and assess outcomes. Implementation outcomes included appropriateness, acceptability, adoption, and penetration.ResultsThe intervention was appropriate and acceptable to primary care and oncology teams based on reported patient needs and resources and the strength of the evidence supporting intervention components. Active and sustained partnership with system leaders facilitated these outcomes. There was limited adoption and penetration early in implementation because the study was narrowly focused on just breast and colorectal cancer patients. This created barriers to real-world practice where patients with all cancer types receive care. Over time, flexibility intentionally designed into intervention implementation facilitated adoption and penetration. Regular feedback from system partners and rapid cycles of implementation and evaluation led to real-time adaptations increasing adoption and penetration.DiscussionEvidence-based interventions to coordinate care for underserved cancer survivors across oncology and primary care teams can be implemented successfully when system leaders are actively engaged and with flexibility in implementation embedded intentionally to continuously facilitate adoption and penetration across the health system.

Study protocol for Care cOORDInatioN And sympTom managEment (COORDINATE) programme: a feasibility study

IntroductionSustainable approaches to support care coordination and symptom management needs of critically ill adults living with multimorbidity are needed to combat the challenges and complexity that multimorbidity presents. The study...

Understanding care coordination for Veterans with complex care needs: protocol of a multiple-methods study to build evidence for an effectiveness and implementation study.

For patients with complex health and social needs, care coordination is crucial for improving their access to care, clinical outcomes, care experiences, and controlling their healthcare costs. However, evidence is inconsistent regarding the core elements of care coordination interventions, and lack of standardized processes for assessing patients' needs has made it challenging for providers to optimize care coordination based on patient needs and preferences. Further, ensuring providers have reliable and timely means of communicating about care plans, patients' full spectrum of needs, and transitions in care is important for overcoming potential care fragmentation. In the Veterans Health Administration (VA), several initiatives are underway to implement care coordination processes and services. In this paper, we describe our study underway in the VA aimed at building evidence for designing and implementing care coordination practices that enhance care integration and improve health and care outcomes for Veterans with complex care needs. In a prospective observational multiple methods study, for Aim 1 we will use existing data to identify Veterans with complex care needs who have and have not received care coordination services. We will examine the relationship between receipt of care coordination services and their health outcomes. In Aim 2, we will adapt the Patient Perceptions of Integrated Veteran Care questionnaire to survey a sample of Veterans about their experiences regarding coordination, integration, and the extent to which their care needs are being met. For Aim 3, we will interview providers and care teams about their perceptions of the innovation attributes of current care coordination needs assessment tools and processes, including their improvement over other approaches (relative advantage), fit with current practices (compatibility and innovation fit), complexity, and ability to visualize how the steps proceed to impact the right care at the right time (observability). The provider interviews will inform design and deployment of a widescale provider survey. Taken together, our study will inform development of an enhanced care coordination intervention that seeks to improve care and outcomes for Veterans with complex care needs.

Indiana Palliative Excellence in Alzheimer’s Care Efforts (IN-PEACE): Protocol for a randomized controlled trial in persons with advanced dementia

BackgroundDementia affects 6.5 million persons in the U.S., a number which is expected to double by 2060. More than half of persons with dementia die at home, creating an enormous burden for both patients and caregivers. However, there is a paucity of research on community-based palliative care interventions for advanced dementia. ObjectivesThe Indiana Palliative Excellence in Alzheimer's Care Efforts (IN-PEACE) study is a randomized trial to test the effectiveness of a collaborative predominantly telehealth home-based intervention for persons with advanced dementia residing in the community and their primary, informal caregivers. The primary aim is to determine if this palliative care focused supportive intervention is superior to usual care in reducing neuropsychiatric symptoms of dementia. Secondarily, intervention effects on other patient symptoms (e.g., pain), caregiver distress and depression, and emergency department (ED)/hospitalization events are examined. MethodsThe study population consists of participant pairs comprising a person with dementia and their primary, informal caregiver. The person with dementia must be ≥65 years old, with a clinical diagnosis of moderate to severe dementia. A total of 201 demographically and socioeconomically diverse participant pairs have been randomized to the IN-PEACE care coordination intervention (n = 99) or usual care (n = 102). Outcome assessments are conducted at baseline, and quarterly for up to 2 years (3, 6, 9, 12, 15, 18, 21, and 24 months). DiscussionIN-PEACE results will inform care for the large number of individuals with advanced dementia residing in the community and enable informal caregivers to provide effective home-based care.Trial registration: clinicaltrials.gov Identifier: NCT03773757.

Supporting families through paediatric brain tumour: Unmet needs and suggestions for change.

From diagnosis and beyond, a paediatric brain tumour and its treatment impact the child and their family in a myriad of ways. While it is considered best practice to offer ongoing psychosocial support for all family members, there is little scholarly investigation of both families' experiences and the practical implications of offering such care. We aimed to explore families' experiences of paediatric brain tumour and their associated psychosocial health service needs. Families receiving care at the Queensland Children's Hospital in Brisbane, Australia, for a child (0-18years) who had been diagnosed with a brain tumour between 2019 and 2022 were invited to be interviewed about their experiences. Using qualitative description, we analysed these interviews to identify families' unmet psychosocial health service needs and their suggestions for improvement. Twenty-three clinically and socially diverse families were represented. While parents/carers expressed gratitude for the care their child had received, most also described unmet needs for the broader family. We identified three primary needs to be addressed: (1) parents want accessible psychological/emotional support for themselves; (2) parents/carers want additional guidance to navigate the hospital setting to reduce uncertainty and loss of control; and (3) parents want support to minimise treatment-associated trauma for their child. Our findings evidence the need for improved family-centred psychosocial care within paediatric brain tumour care in Queensland, Australia. We propose a counselling and care coordination intervention to support parents/carers to care for themselves, their child, and their family through an extremely challenging experience.

Research-practice partnerships: Adapting a care coordination intervention for rural Veterans over 3 years at multiple sites.

Rural Veterans are more likely than urban Veterans to qualify for community care (Veterans Health Administration [VHA]-paid care delivered outside of VHA) due to wait times ≥30 days and longer travel times for VHA care. For rural Veterans receiving both VHA and community care, suboptimal care coordination between VHA and community providers can result in poor follow-up and care fragmentation. We developed Telehealth-based Coordination of Non-VHA Care (TECNO Care) to address this problem. We iteratively developed and adapted TECNO Care with partners from the VHA Office of Rural Health and site-based Home Telehealth Care in the Community programs. Using templated electronic health record notes, Home Telehealth nurses contacted Veterans monthly to facilitate communication with VHA/community providers, coordinate referrals, reconcile medications, and follow up on acute episodes. We evaluated TECNO Care using a patient-level, pre-post effectiveness assessment and rapid qualitative analysis with individual interviews of Veterans and VHA collaborators. Our primary effectiveness outcome was a validated care coordination quality measure. We calculated mean change scores for each care continuity domain. Between March 2019 and October 2021, 83 Veterans received TECNO Care. Veterans were predominately White (86.4%) and male (88.6%) with mean age 71.4 years (SD 10.4). Quantitative data demonstrated improvements in perceived care coordination following TECNO Care in 7 categories. Qualitative interviews indicated that Veterans and Home Telehealth nurses perceived TECNO Care as beneficial and addressing an area of high need. TECNO Care appeared to improve the coordination of VHA and community care and was valued by Veterans.

BUDGET IMPACT ANALYSIS OF NONPHARMACOLOGICAL INTERVENTIONS FOR COMMUNITY-DWELLING PEOPLE LIVING WITH DEMENTIA

Abstract Non-pharmacologic dementia care interventions significantly reduce the risk of a nursing home admission for people living with dementia. We used an evidence-based mathematical model to evaluate the budget impact for a healthcare payer that independently implemented four non-pharmacologic dementia care interventions that reduce the risk of transitioning to a nursing home for people living with dementia: 1) MIND, an at-home care coordination intervention; 2) NYU Caregiver (NYUCI), provides caregivers with counseling and ad-hoc support; 3) Alzheimer’s and Dementia Care (ADC) program, a clinic based care coordination intervention; and 4) Adult Day Services Plus (ADS-Plus), an adult day based care coordination intervention. Healthcare payer costs included Medicare and Medicaid expenditures. We simulated a cohort of 302,630 community-dwelling people with dementia, which is the number of people who were diagnosed with dementia in 2018. We applied each intervention’s inclusion criteria to determine the proportion of the cohort that would receive the interventions. Some people may die or enter a nursing home before receiving the interventions. MIND, NYUCI, ADC, and ADS-Plus reduced annual payer expenditures (relative to $25,000, which is the average amount Medicare-Medicaid pay per person with dementia) on average by 0.67%, 0.23%, 0.13%, and 0.58%, respectively over 5 years. Cost savings for the interventions varied by demographics. African American females between ages 95-100 who received NYUCI had the largest cost savings ($2,750.57). White females between ages 65-70 who received ADC had an increase in payer costs ($2,397.07). On average, non-pharmacologic dementia care intervention do not increase a healthcare payer’s budget.

Exploring Service Use Disparities among Suicidal Black Youth in a Suicide Prevention Care Coordination Intervention.

The aim of this study is to examine service utilization disparities among Black youth participating in Linking Individuals Needing Care (LINC), a 90-day research-informed suicide care coordination intervention. An open trial pilot was conducted to examine the effectiveness of LINC in increasing access to and engagement in mental health and non-mental health services among suicidal youth (N = 587). Other variables of interest included service use facilitators and service use barriers. Generalized linear mixed models with binomial distribution and logit link were performed to ascertain if service use facilitators and barriers were associated with service utilization and if disparities in service use and engagement existed between Black and White suicidal youth through a comparative analysis. Service utilization differences were found between Black and White youth. While Black and White youth were both likely to engage in individual therapy (OR = 1.398, p < .001) and non-mental health services (OR = 1.289, p < .001), utilization rates for mental health and medication management services were lower for Black (55.1% to 60.6%) youth compared to White (66.0% to 71.0%) youth. Specifically, Black youth were significantly less likely than Whites to receive medication management (OR = .466, p = .002). Systemic barriers such long waitlists for care (OR = 1.860, p = .039) and poor relationship with providers (OR = 7.680, p = .028) increased odds of engagement in non-mental health services. Clinical disorders and engagement in suicide-related behaviors increased the likelihood of obtaining care from both medication management and non-mental health services. Care coordination services for suicidal youth can increase access and engagement in mental health and non-mental health services. Culturally adapted models attending to cultural and social assets of Black families are needed to reduce disparities and suicide risk among Black youth.

Improving Care for Families and Children with Neurodevelopmental Disorders and Co-occurring Chronic Health Conditions Using a Care Coordination Intervention.

This clinical intervention study aimed to improve care integration and health service delivery for children with concurrent neurodevelopmental disorders and chronic health conditions. This population has significant unmet needs and disproportionate deficits in service delivery. A lack of coordination across child service sectors is a common barrier to successful treatment and support of children with neurodevelopmental disorders with complex medical needs. This project implemented an innovative care coordination model, involving one-on-one supports from a trained care coordinator who liaised with the broader intersectoral care team to improve joint care planning, integration of services, and the experience of both families and care providers. To evaluate the impact of care coordination activities, a single-group interventional study was conducted using a repeated-measures framework (at 0, 6, and 12 months) using previously established outcome measures. Over 2 years, this project provided care coordination to 84 children and their families, with an age range from 2 to 17 years. The care coordination intervention demonstrated positive impacts for children, families, and care teams and contributed to clinical efficiencies. Children had fewer visits to the emergency department and less frequent acute care use. Improvement in access to services, joint care planning and communication across providers, and better linkage with school supports were demonstrated. Families reported that the program decreased their stress around coordinating care for their child. This work demonstrated that intersectoral care coordination is attainable through innovative and collaborative practice for children with complex neurodevelopmental and medical needs.

137-LB: Unmet Social Needs and Uptake of Recommended Diabetes Processes of Care in a High-Need, High-Cost Medicaid Population

Diabetes patients with unmet social needs (e.g., housing instability, food insecurity) may be less able to complete recommended processes of care than patients without these challenges. We examined survey data from a multi-state sample of Medicaid patients with diabetes (n=6,087) identified by UnitedHealthcare as high-cost, high-need based on utilization over the past year, who were enrolled in a comprehensive care coordination intervention by Optum. Before receiving any intervention services, patients reported whether they experienced housing instability, food insecurity, transportation problems, need for help with utilities, or feared for their interpersonal safety at baseline. We used data from administrative claims to measure whether these patients had 4 recommended processes of care completed within the last 18 months: 1) retinal exam, 2) ACE/ARB medication or nephropathy screening, 3) A1c testing, or 4) statin prescription ordered. We examined the cross-sectional association between unmet social needs and processes of care using multivariate logistic regression, controlling for clustering by zip code. The analytic sample was 50% White and 61% female, with 5.6 documented comorbidities on average. Overall, rates of unmet social need varied from 4% for concerns about interpersonal safety to 16% for transportation problems. Only 52% of patients had a retinal exam during the study window, 69% were prescribed a statin, 88% had their A1c checked, and 95% were taking an ACE/ARB medication or had nephropathy screening. In the regression analyses, we did not find statistically significant associations between any of the unmet social needs and the processes of care (all p values &amp;gt;0.05) . In this analysis of high-cost, high-need Medicaid patients, barriers other than unmet social needs may underpin difficulties with achieving recommended processes of care for diabetes, particularly retinal exams and statin use that are completed at lower rates. Disclosure O. Duru: None. A. M. Klomhaus: None. C. Mangione: n/a. T. Moin: None. Funding Centers for Disease Control and Prevention U18DP006128

From research to realization: How a Texas health plan implemented an academic model of care for Alzheimer's disease

AbstractMIND at Home is a comprehensive, home‐based care coordination intervention for people with Alzheimer’s disease or related dementias (A/D) who live in the community and for their family caregivers. Developed by researchers at Johns Hopkins University (JHU), the model has been shown to extend the time a person with A/D remains at home for almost two years, as well as improved quality of life and quality of care and reduced caregiver burden. The MIND at Home pilot at Superior HealthPlan is a collaboration between Centene Corporation, JHU, and Superior HealthPlan (Superior). The goal of the MIND at Home pilot is to adapt, implement, and evaluate the impact of MIND at Home within Superior’s Medicaid population. The pilot is structured as an interventional study of the MIND at Home program versus a propensity score‐matched (PSM) comparison group receiving standard‐of‐care. The duration of the pilot is approximately 12 months, with longitudinal follow‐up at 18 and 24 months. The pilot population includes Superior HealthPlan Medicaid members (receiving Long‐Term Services &amp; Supports) who are community‐residing and have a confirmed diagnosis of A/D. The study has enrolled approximately 300 participants who have received the intervention. An analysis of claims data for participants receiving the MIND at Home intervention indicates the program increased primary care utilization (+10.0%) while reducing emergency department (ED) utilization (‐15.8%), polypharmacy (‐5.0%), and total spend (‐1.35%). Consumer survey results indicate high levels of satisfaction among both pilot participants and their family caregivers and case studies anecdotally illustrate the significant impacts the MIND at Home program has had on participant and caregiver quality of life. Preliminary outcomes of the pilot indicate the MIND at Home program reduces high cost healthcare utilization – particularly ED and polypharmacy – and overall participant costs. Additional outcomes illustrate participants are highly satisfied with the MIND at Home program and have experienced dramatic increases in quality of life. This pilot showcases the value of operationalizing this evidence‐based academic care model for A/D in a Medicaid population and that collaboration across academic research, industry, and government‐sponsored healthcare programs can result in improved outcomes for individuals with A/D.

Characterizing Low-Risk Breast and Gynecological Cancer Patients for Transition into an Oncology/Primary Care Coordinated Care Model: Findings from a Survey of Diverse Survivors in a Rural U.S. State.

Simple SummaryWe conducted a survey to identify the key aspects that influence cancer care for racial/ethnic and geographically diverse low-risk breast and gynecologic cancer patients. New Mexico is a large state with many ethnic and racially diverse communities who reside in rural areas. Data obtained through our New Mexico Tumor Registry show that these patients often have different and worse cancer health outcomes. To learn more about how to improve their care, we surveyed patients regarding their access to primary care (PC); compliance with screening recommendations; treatment for conditions other than cancer (e.g., diabetes, obesity, heart problems, etc.); difficulties attending their clinic visits; and whether or not they received information about their survivorship care in the form of a survivorship care document (SCD). We found that the majority of the 150 patients surveyed reported having a Primary Care Provider (PCP). Many had health complications other than cancer, those who resided in rural areas had more difficulties getting to their cancer follow-up appointments, and nearly half had not received SCDs. We used these survey results to develop an oncology/PCP care coordination intervention to improve the oncology and cancer survivorship care for those who were at low risk of recurrence.We conducted a survey to characterize the key attributes of racial/ethnic and geographically diverse low-risk breast and gynecologic cancer patients. We collected data regarding patients’ access to primary care (PC); compliance with screening recommendations; treatment for comorbidities; logistical barriers to clinic visits; and receipt of survivorship care documentation (SCD). Survey findings informed the development of an oncology/Primary Care Provider (PCP) care coordination intervention to improve care. We distributed a cross-sectional survey among a convenience sample of 150 cancer survivors. Responses were calculated using descriptive statistics and compared based on the distance participants traveled to their appointments at the cancer center (≤30 vs. >30 miles). Of the 150 respondents, 35% traveled >30 miles for follow-up care and 78% reported having one or more comorbid condition(s). PC utilization was high: 88% reported having a PCP, and 91% indicated ≤1 yearly follow-up visit. Participants traveling >30 miles reported higher rates of logistical challenges associated with cancer center visits compared to those traveling ≤30 miles. Nearly half of respondents (46%) had not received SCD. In conclusion, survey studies such as these allow for the systematic assessment of survivor behaviors and care utilization patterns to inform the development of care coordination interventions for diverse, low-risk cancer patients.

A Care Coordination Intervention Improves Symptoms But Not Charges in High-Risk Patients With Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is associated with substantial symptom burden, variability in clinical outcomes, and high direct costs. We sought to determine if a care coordination-based strategy was effective at improving patient symptom burden and reducing healthcare costs for patients with IBD in the top quintile of predicted healthcare utilization and costs. We performed a randomized controlled trial to evaluate the efficacy of a patient-tailored multicomponent care coordination intervention composed of proactive symptom monitoring and care coordinator-triggered algorithms. Enrolled patients with IBD were randomized to usual care or to our care coordination intervention over a 9-month period (April 2019 to January 2020). Primary outcomes included change in patient symptom scores throughout the intervention and IBD-related charges at 12 months. Eligible IBD patients in the top quintile for predicted healthcare utilization and expenditures were identified. A total of 205 patients were enrolled and randomized to our intervention (n= 100) or to usual care (n= 105). Patients in the care coordinator arm demonstrated an improvement in symptoms scores compared with usual care (coefficient, -0.68, 95% confidence interval, -1.18 to -0.18; P= .008) without a significant difference in median annual IBD-related healthcare charges ($10,094 vs $9080; P= .322). In this first randomized controlled trial of a patient-tailored care coordination intervention, composed of proactive symptom monitoring and care coordinator-triggered algorithms, we observed an improvement in patient symptom scores but not in healthcare charges. Care coordination programs may represent an effective value-based approach to improve symptoms scores without added direct costs in a subgroup of high-risk patients with IBD. (ClinicalTrials.gov, Number: NCT04796571).

Evaluation of an intervention targeted with predictive analytics to prevent readmissions in an integrated health system: observational study

ObjectivesTo determine the associations between a care coordination intervention (the Transitions Program) targeted to patients after hospital discharge and 30 day readmission and mortality in a large, integrated healthcare system.DesignObservational...

Caring Transitions - A Care Coordination Intervention to Reduce Suicide Risk Among Youth Discharged From Inpatient Psychiatric Hospitalization.

Background: Suicide risk following youth psychiatric hospitalization is of significant concern. This study evaluated Linking Individuals Needing Care (LINC), a theory-driven, comprehensive care coordination approach for youth discharged from crisis services. Aims: To pilot LINC's potential effectiveness in increasing service utilization and decreasing suicide risk. Method: Participants were 460 youth patients who received LINC for approximately 90 days following discharge from crisis services. Service utilization, depressive symptoms, and suicide-related variables were measured at baseline and 30, 60, and 90 days after baseline. Results: Patients significantly increased the use of various beneficial, least restrictive services (individual therapy, medication management, and non-mental health supports) over the 90-day intervention. Significant decreases were observed in depressive symptoms, suicide ideation, and engagement in suicide-related behaviors. Limitations: Absence of a comparison group and nonparticipating families limit causal conclusions and generalizability. Conclusions: LINC may be a promising new approach following inpatient hospitalization that can engage and retain youth in services, likely resulting in improved treatment outcomes. This approach was designed emphasizing patient engagement, suicide risk assessment and management, safety planning, community networking, referral/linkage monitoring, coping and motivational strategies, and linguistic/culturally responsive practices to meet service and support needs of high-risk suicidal youth.

Transitions of Care Coordination Intervention Identifies Barriers to Discharge in Hospitalized Stroke Patients.

Background: Prolonged hospital lengths of stay increase costs, delay rehabilitation, and expose acute ischemic stroke patients to hospital-acquired infections. We designed and implemented a nurse-driven transitions of care coordinator (TOCC) program to facilitate the transition of care from the acute care hospital setting to rehabilitation centers and home.Methods: This was a single-blinded, prospective, randomized pilot study of 40 participants to evaluate the feasibility of implementing a TOCC program led by a stroke nurse navigator in hospitalized acute ischemic stroke patients. The intervention consisted of a stroke nurse navigator completing eight specific tasks, including meeting with stroke patients and their families, facilitating communication between team members at multi-disciplinary rounds, assisting with referrals to rehabilitation facilities, providing stroke education, and arranging stroke clinic follow-up appointments, which were confirmed to be completed by independent study personnel. The primary outcome was to assess the feasibility of the program. The secondary outcomes included comparing hospital length of stay (LOS) and patient satisfaction between the TOCC and usual care groups. We also explored the association between patient-level variables and LOS.Results: The TOCC program was feasible with all pre-specified components completed in 84.2% (95% CI: 60.4–96.6%) and was not significantly different from the assumed completion rate of 75% (p = 0.438). There was no significant difference in median LOS between the two groups [TOCC 5.95 days (4.02, 9.57) vs. usual care 4.01 days (2.00, 10.45), false discovery rate (FDR)-adjusted p = 0.138]. There was a trend toward higher patient median satisfaction in the TOCC group [TOCC 35.00 (33.00, 35.00) vs. usual care 30 (26.00, 35.00), FDR-adjusted p = 0.1] as assessed by a questionnaire at 30 days after discharge. The TOCC study allowed us to identify patient variables (gender, insurance, stroke severity, and discharge disposition) that were significantly associated with longer hospital LOS.Conclusion: A TOCC program is feasible and can serve as a guide for future allocation of resources to facilitate transitions of care and avoid prolonged hospital stays.