Health care hotspotting: inside the Camden Coalition's superutilizer program

摘要 该项目扩展了卡姆登医疗保健联盟的随机对照试验的分析 提供者的复杂护理管理计划，旨在减少支出和改善 通过针对医疗保健系统的“超级利用者”，提高医疗保健质量和健康结果。程序 专注于患有慢性病，复杂需求和频繁住院的患者，与他们合作 以防止将来再次入院该计划的动机是，医疗保健费用（其中 占美国GDP的近18%）高度集中。它的目标群体是 不到卡姆登人口的2%，但超过卡姆登总支出的四分之一 医院的 我们之前的随机对照试验发现，护理协调计划未能减少住院时间， 重新接纳，但无法解释原因。这项后续研究将通过以下方式解决这个悬而未决的问题： 研究新的结果，区分两种截然不同的解释， 含义：试验对计划或计划背后的基础理论的忠实度失败。是 出院后护理协调（如及时让患者接受初级护理预约）， 是否已达到或不足以防止重新接纳？这项工作是一个难得的机会， 对一项至关重要但有限的随机对照试验进行尸检，并为改善医疗护理指明前进道路。 社交复杂的病人。 我们利用丰富的医疗补助数据来调查这些对缺乏计划影响的替代解释。 医院再入院，扩大调查范围超出医院利用率，以阐明该计划的 对其他重要的医疗保健利用和健康行为的影响，这是该计划的关键要素 变革理论。具体目标的动机是需要更好地了解医院的无效结果 重新接纳，告知当前对其解释的辩论，并调查 在医院外进行干预。我们将使用随机对照设计来研究 卡姆登计划对（1）门诊护理数量的影响，包括初级护理，专科护理， 处方药、家庭护理和耐用医疗设备;（2）门诊护理质量，由 照顾分散的措施，以及出院后是否及时接受照顾;及（3） 患者健康行为，包括药物依从性和医疗补助登记的稳定性。我们将 还与项目工作人员进行访谈，以了解实施挑战，了解调查结果的背景， 并产生新的假设

ABSTRACT This project extends the analysis of a randomized controlled trial of the Camden Coalition of Healthcare Providers’ complex care management program, an intervention that aims to reduce spending and improve healthcare quality and health outcomes by targeting “superutilizers” of the healthcare system. The program focuses on patients with chronic conditions, complex needs, and frequent hospitalizations, working with them after discharge to prevent future admissions. The program is motivated by the fact that healthcare costs (which account for almost 18 percent of GDP in the US) are heavily concentrated. It targets a group that accounts for less than two percent of the Camden population but more than a quarter of total spending at Camden hospitals. Our previous randomized controlled trial found that the care coordination program failed to reduce hospital readmissions, but it could not explain why. This follow-up research will address this unanswered question by investigating new outcomes that distinguish between two very different explanations with very different implications: a failure of trial fidelity to the program or of the underlying theory behind the program. Was postdischarge care coordination (such as getting patients to primary care appointments in a timely manner) not achieved or was it insufficient to prevent readmissions? This work is a rare opportunity to conduct a postmortem on a critically important but limited RCT and chart a path forward for improving care for medically and socially complex patients. We leverage rich Medicaid data to investigate these alternative explanations for the lack of program impact on hospital readmissions, expanding the scope of inquiry beyond hospital utilization to shed light on the program’s impact on other important healthcare utilization and health behaviors, which are key elements of the program’s theory of change. The specific aims are motivated by a need to better understand the null findings on hospital readmissions, inform the current debate over their interpretation, and investigate potential impacts of the intervention outside of the hospital setting. We will use the randomized controlled design to investigate the impact of the Camden program on (1) Quantity of outpatient care, including primary care, specialist care, prescription drugs, home care, and durable medical equipment; (2) Quality of outpatient care, as proxied by measures of care fragmentation and whether care was received in a timely manner after discharge; and (3) Patient health behaviors, including medication adherence and the stability of enrollment in Medicaid. We will also conduct interviews with program staff to understand implementation challenges, contextualize findings, and generate new hypotheses.