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Transforming Outcomes for Patients Through Medical Home Evaluation & reDesign (TOPMED)

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details.
 
ClinicalTrials.gov Identifier: NCT02106221
Recruitment Status : Completed
First Posted : April 8, 2014
Last Update Posted : July 29, 2015
Sponsor:
Collaborator:
Gordon and Betty Moore Foundation
Information provided by (Responsible Party):
Care Management Plus

Study Description
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Brief Summary:

The purpose of this study is to support enhancement, implementation, and evaluation of an improved model for delivering improved primary care to high-risk older adults through the use of health IT tools, focusing on issues related to the patient-centered primary care home (PCPCH) and other similar high-value elements that are proposed to improve patient outcomes. During this study, participating clinics will utilize the already-implemented Integrated Care Coordination Information System (ICCIS). Clinic staff will meet with a practice facilitator (monthly and as needed), and will track study activities and submit invoices via ICCIS reporting. These invoices will be used to simulate a shared savings model where clinics will be reimbursed based on their progress and effort towards their goals.

Clinics will set and work towards goals that they have chosen. Goals for the control arm are self-selected by the clinics themselves; goals for the invention arm are related to high-value elements (HVE) that have been identified as areas that can improve patient outcomes. These HVE are:

  1. Evidence-based Care Management Based on Need
  2. Identification of At-Risk Populations
  3. Patient Engagement and Alerts Based on Goals
  4. Integrated Information for Care Management, especially around Utilization
  5. Population Management Tools

Condition or disease Intervention/treatment Phase
Nurse Based Care Management Health Information Technology Other: Intervention Other: Control Phase 3

Study Design
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Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 65500 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single (Participant)
Primary Purpose: Supportive Care
Official Title: Transforming Outcomes for Patients Through Medical Home Evaluation & reDesign
Study Start Date : July 2011
Actual Primary Completion Date : June 2014
Actual Study Completion Date : February 2015
Arms and Interventions
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Arm Intervention/treatment
Experimental: Intervention
Financial incentives will be provided based on performance in areas determined to be of high-value.
 Other: Intervention
Will receive payments based on achievement in meeting goals based on specified high value elements as well as effort.
Active Comparator: Control
Financial incentives are a flat rate which can be reduced if an appropriate amount of effort or improvement is not met
 Other: Control
Will receive payments based on achievement in meeting goals.


Outcome Measures
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Primary Outcome Measures :
  1. Preventable utilization [ Time Frame: 12 months ]
    Reduce by 15% ED visits and hospitalizations related to ambulatory care

  2. Quality Measures Improvement [ Time Frame: 12 months ]
    Select 3 standard measures related to the patient population and improve each by 20%. (An example of such a measure might be fall risk assessment. There are several quality measures that are included as part of the HIT tool that is provided to clinics.)

  3. Patient Satisfaction [ Time Frame: 12 months ]
    Improve patient experience with clinic and satisfaction with care coordination by 10% Patient satisfaction will be determined by a CAHPS patient satisfaction survey that is sent out at the start and end of the study.


Eligibility Criteria
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Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • clinics must be from the Oregon Rural Practice-based Research Network (ORPRN)
  • Primary care clinic meeting one of the following health care setting descriptions: 1) small clinics in rural area, 2) medium-sized clinics in rural area, 3) clinics in moderate-sized health system, or 4) clinic within an academic medical center;
  • Clinic will or has attested for PCPCH, achieving Tier 2 or 3 (of 3 tiers);
  • Clinic is willing to contract to be a PCPCH with payers;
  • Clinic has stable electronic health record (EHR) system with no plans to change systems during study duration;
  • Clinic has willingness to receive practice facilitation and participate in study activities, including completion of assessments;
  • Clinic has willingness to engage with research team members as defined in the study.

Exclusion Criteria:

  • patients less then 18
Contacts and Locations
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Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT02106221


Locations
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United States, Oregon
Oregon Health & Science University
Portland, Oregon, United States, 97239
Sponsors and Collaborators
Care Management Plus
Gordon and Betty Moore Foundation
Investigators
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Principal Investigator: David A Dorr, MD, MS Oregon Health and Science University
Study Chair: Marsha Pierre-Jacques Williams, BA Oregon Health and Science University
Study Chair: Kimberley Gray, BSN Oregon Health and Science University
More Information
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Publications:

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Responsible Party: Care Management Plus
ClinicalTrials.gov Identifier: NCT02106221    
Other Study ID Numbers: GBMF2908
First Posted: April 8, 2014    Key Record Dates
Last Update Posted: July 29, 2015
Last Verified: July 2015
Keywords provided by Care Management Plus:
Care coordination
nurse care management
practice facilitation
health information technology