A Randomized Controlled Trial of Health Care Hotspotting

 描述(由申请人提供)：卡姆登医疗保健提供者护理管理计划联盟：Link2Care，被认为是同时降低医疗保健成本和改善患者健康的最有前途的方法之一。该计划针对的是医疗保健系统的“超级利用者”--特别是有两次或两次以上住院经历的成年人。 前六个月和多种慢性疾病--在出院后的几个月内接受重症监护管理服务。由护士、社会工作者、社区卫生工作者和健康教练组成的团队，在医疗保健使用的实时数据的支持下，进行家访，陪同患者就诊，并帮助患者登记参加社会服务计划。这种方法旨在提高患者在医疗保健和社会服务系统中的自给自足能力，并有可能减少医院使用，改善患者的福祉。该项目将通过随机对照试验严格调查该计划对后续医疗保健利用和社会服务使用的影响。

 DESCRIPTION (provided by applicant): The Camden Coalition of Healthcare Providers' Care Management Program: Link2Care, is considered one of the most promising ways to reduce healthcare costs and improve patient health at the same time. The program targets "super-utilizers" of the health care system - specifically adults with two or more hospitalizations in the prior six months and multiple chronic conditions - with intensive care-management services in the months following hospital discharge. A team of nurses, social workers, community health workers and health coaches, supported by real-time data of healthcare use, perform home visits, accompany patients to doctor visits, and help patients enroll in social-service programs. This approach aims to improve the self-sufficiency of patients in navigating the healthcare and social-service systems and has the potential to reduce hospital use and improve patient well-being. This project will rigorously investigate the impacts of the program on subsequent healthcare utilization and the use of social services through a randomized controlled trial.