A Randomized Controlled Trial of Health Care Hotspotting

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 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.