A Pragmatic Nationwide RCT of Coordinated Medical, Behavioral, and Social Services to Improve Care and Utilization among High-Cost, High-Need Insured Patients with Diabetes

项目摘要/摘要 我们的加州大学洛杉矶分校团队与联合医疗集团(UHC)合作，提议达成一项合作协议 与美国疾病控制与预防中心合作，评估UHC国家护理协调(NCC)计划与创新护理的影响 旨在同时解决健康的医疗、行为和社会决定因素的模型 美国疾病最严重、费用最高的商业保险人。NCC是一个现实世界的关怀机构 旨在提供“全人护理”的协调计划，将强化医疗、行为和 在社区一级提供社会支持，以解决除健康的社会决定因素之外的获取障碍， 包括粮食和住房不安全。这项研究的总体目标是运用严谨的实证 评估这一创新计划对成人护理的交付、结果和成本的影响 患有糖尿病的商业参与者。这项拟议的评估是独特的，因为UHC实施了 务实、随机对照试验的NCC计划于2015年至今。 该项目的具体目标如下：目标1将评估UHC的NCC计划是否要减少 在高成本、高需求的糖尿病商业保险受益人中使用将导致减少 糖尿病并发症。这些包括重大心血管事件，急诊室就诊次数减少，以及 住院，更低的总体护理成本(主要终点)，减少截肢，进展缓慢 慢性肾脏疾病和A1c控制的改善以及服药依从性和 糖尿病护理流程(次级终点)。目标2将评估NCC对 糖尿病受益人的三个主要终点因种族或民族而异。Aim 3将比较 NCC在降低护理和利用、特定急诊室就诊和 在患有和不患有糖尿病的受益者中住院治疗。目标4是参与协作的多 旨在加强评估所有自然实验的研究方法的机构网络 网站，并为美国研究界的自然实验提供最佳的分析方法。 我们与UHC进行了15年的高效合作，这使得拟议的研究很有可能 分析这一务实的RCT将是成功的，并将提供急需的证据，以证明 强化的全人护理管理计划可以减少糖尿病相关的并发症、资源 美国一些最脆弱的商业保险糖尿病患者的使用率和成本。

PROJECT SUMMARY/ABSTRACT Our UCLA team, in partnership with United Healthcare (UHC), proposes to form a cooperative agreement with the CDC to evaluate the impact of a UHC national care coordination (NCC) program with innovative care models designed to simultaneously address the medical, behavioral and social determinants of health among the most severely ill and costly commercially insured persons in the US. The NCC is a real-world care coordination program that aims to provide “whole-person care,” integrating intensive medical, behavioral and social support at a community level to address access barriers in addition to social determinants of health, including food and housing insecurity. The overall goal of the research is to employ rigorous empirical evaluation of the impact of this innovative program on the delivery, outcomes, and cost of care for adult commercial enrollees with diabetes. This proposed evaluation is unique because UHC implemented a pragmatic, randomized control trial of the NCC program in 2015 to the present. The specific aims for this project are as follows: Aim 1 will evaluate whether UHC's NCC program to reduce utilization among high-cost, high-need commercially insured beneficiaries with diabetes will lead to reduced diabetes complications. These include major cardiovascular events, fewer emergency room visits and hospitalizations, lower overall costs of care (primary endpoints), reduced amputations, slower progression of chronic kidney disease and improvements in A1c control and improvements in adherence to medications and diabetes processes of care (secondary endpoints). Aim 2 will evaluate whether the influence of the NCC on the three primary endpoints for beneficiaries with diabetes varies by race or ethnicity. Aim 3 will compare the relative effectiveness of the NCC on reducing costs of care and utilization, specific emergency room visits and hospitalizations, among beneficiaries with and without diabetes. Aim 4 is to participate in a collaborative multi- institution network designed to strengthen the research methods for evaluating natural experiments across all sites, and to advance the best analytic methods for natural experiments in the US research community. Our 15 year, highly productive collaboration with UHC makes it very likely that the proposed research analyzing this pragmatic RCT will be successful and will provide critically needed evidence about whether intensive, whole-person care management programs can reduce diabetes related complications, resource utilization, and costs for some of the most vulnerable commercially insured persons with diabetes in the US.