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

摘要 该项目扩展了对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 通过瞄准医疗系统的“超级利用者”，提高医疗质量和健康结果。该计划 重点关注慢性病、复杂需求和频繁住院的患者，与他们合作 在出院后，以防止未来的入院。该计划的动机是医疗费用(其中 占美国GDP的近18%)高度集中。它的目标群体是占 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。 我们之前的随机对照试验发现，护理协调计划未能减少医院 重新入院，但无法解释原因。这项后续研究将通过以下方式解决这一悬而未决的问题 研究区分两种截然不同的解释的新结果 暗示：试验对计划或计划背后的基本理论的忠诚度的失败。曾经是 出院后护理协调(如及时让病人到初级保健预约)不 是否已达到或不足以阻止重新接纳？这项工作是一次难得的机会 对一项极其重要但有限的RCT进行尸检，并为改善医疗保健制定前进道路 以及社交复杂的病人。 我们利用丰富的医疗补助数据来调查这些对计划缺乏影响的替代解释 再次住院，将调查范围扩大到医院利用之外，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，这些都是该计划的关键要素 变化论。具体目标的动机是需要更好地理解关于医院的无效发现 重新接纳，告知目前关于他们的解释的辩论，并调查 医院环境外的干预。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，包括初级保健、专科护理、 处方药、家庭护理和耐用的医疗设备；(2)门诊护理的质量，由 护理分散的措施，以及出院后是否及时得到护理；和(3) 患者的健康行为，包括服药依从性和参加医疗补助的稳定性。我们会 还与计划人员进行面谈，以了解实施挑战，将结果与背景相结合， 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.