Status:
COMPLETED
Integrated Care (IC) Models for Patient-Centered Outcomes
Lead Sponsor:
University of Pittsburgh
Collaborating Sponsors:
Patient-Centered Outcomes Research Institute
Conditions:
Diabetes
Asthma
Eligibility:
All Genders
21+ years
Phase:
NA
Brief Summary
Multiple chronic conditions (MCC) are widely recognized as the U.S. public health challenge of the 21st century. These physical and behavioral health conditions take a large toll on those living with ...
Detailed Description
Study aims. Given the documented need for valuable information about system-level features that can be used to effectively and efficiently support adults in living well with MCC, this study is designe...
Eligibility Criteria
Inclusion
- Medicaid or dual-eligible (Medicare-Medicaid) adults, ages 21 years and older with Multiple Chronic Conditions (MCC).
- Have at least one physical health condition (e.g., cardiovascular disease, hypertension, COPD, diabetes).
- Have at least one additional physical or behavioral health condition (e.g., depression, serious mental illness, substance abuse disorder).
- Reside in Western, Central, or Eastern Pennsylvania.
- Be insured through physical and/or behavioral health payers within the UPMC ISD.
- Individuals will have several comorbidities, will have been prescribed several medications, and/or will be predicted future high health care utilizers.
- Must have at least one hospital discharge within 30 days of enrollment.
- Speak and read English or Spanish at a 4th grade level.
Exclusion
- Individuals receiving advanced levels of care, including:
- Individuals who are pregnant.
- Individuals in skilled nursing facilities or receiving hospice or palliative care.
- Individuals on hemodialysis for kidney disease.
- Individuals whose inpatient admission was related to active cancer treatment.
- Individuals currently enrolled in an RPM program.
- Individuals who have participated in High-Touch or High-Tech within the previous 12 months.
- Individuals who are unable to operate a smart phone due to limitations in literacy, vision, or dexterity.
Key Trial Info
Start Date :
September 4 2018
Trial Type :
INTERVENTIONAL
Allocation :
ACTUAL
End Date :
November 30 2022
Estimated Enrollment :
1400 Patients enrolled
Trial Details
Trial ID
NCT03451630
Start Date
September 4 2018
End Date
November 30 2022
Last Update
December 9 2024
Active Locations (1)
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1
UPMC
Pittsburgh, Pennsylvania, United States, 15219