IT to Support Integration of Social Determinant of Health Services to Reduce Avoidable Emergency Department Visits

Overview

Working through regional Accountable Care Organizations (ACO) the sponsor will establish a 2-year pilot project to demonstrate that early recognition and intervention in the various Social Determinant of Health (SDoH) domains can reduce avoidable Emergency Department (ED) visits by high utilizers. The regional ACO's will contract with Medicaid Managed Care Plans to assign traditional high ED utilizing members to the pilot project. Members will be offered enhanced peer facilitated care management services connecting members with available SDoH community based services. Members fitting our eligibility criteria will self-select by way of completing a pilot project consent form.

Full Title of Study: “Use of Information Technology to Support Integration of Social Determinant of Health Services to Reduce Avoidable Emergency Department Visits”

Study Type

  • Study Type: Interventional
  • Study Design
    • Intervention Model: Single Group Assignment
    • Primary Purpose: Supportive Care
    • Masking: None (Open Label)
  • Study Primary Completion Date: June 30, 2022

Detailed Description

The project employs a two level intervention to include Peer Support Specialist (PSS) and Community Health Advocate (CHA). Contact and engagement with participating members will be through both direct intervention in the emergency department by Peer Support Specialist (the peer) as well as in the community for prevention visits and follow up by both the peer and Community Health Advocate. These well-positioned Peers and Community Health Advocates will address Behavioral and Social Determinants of Health (SDoH) concerns through a highly coordinated intervention supported by a common IT Medicaid member tracking platform. This research project will determine the feasibility of deploying a single shared IT platform that will include referral, appointment completion, and intervention outcome data. Project staff will develop a trusting relationship with the members and will improve member access and engagement with community-based services. The project will also seek to determine the impact on total cost of care through redirecting study participants to community resources that are more appropriate, and less expensive than return visits to the emergency department.

Interventions

  • Behavioral: Peer Integrated Care Services
    • The project employs a two level intervention to include Peer Support Specialist (PSS) and Community Health Advocate (CHA). Contact and engagement with participating members will be through both direct intervention in the emergency department as well as in the community for prevention visits and follow up. Peers and Community Health Advocates will address Behavioral and Social Determinants of Health (SDoH) concerns through a coordinated intervention supported by a common IT Medicaid member tracking platform. This research project will determine the feasibility of deploying a single shared IT platform that will include referral, appointment completion, and intervention outcome data. Project staff will develop a relationship with the members improving member access and engagement with community-based services. The project will determine the impact on total cost of care through redirecting study participants to community resources rather than return visits to the emergency department.

Arms, Groups and Cohorts

  • Experimental: Medicaid Emergency Department High Utilizers
    • This Arm will include the following individuals Up to 400 Adults age 18 to 65 New York State Medicaid Managed Care Members Have utilized emergency department services 6 or more times in a 12-month period Have been assigned to the Pilot Project by their Medicaid Managed Care Plan

Clinical Trial Outcome Measures

Primary Measures

  • Change in Adoption and Use of IT Platform
    • Time Frame: Months 6, 12, 18, 24
    • Change in Number of Participating Agencies That Contribute Data to the IT System
  • Change in Engagement of Medicaid Member Participants with Peer Integration Care Services
    • Time Frame: Months 0, 3, 6, 9, 12, 15, 18, 21, 24
    • The change in acceptance by Medicaid Members of Peer Integrated Care Services
  • Change in Total Cost of Care for Participating Members
    • Time Frame: Month 0, Month 24
    • Change in cost trend for participating members. Pre-study vs. study period.

Secondary Measures

  • Change in Emergency Room Visits by Participating Members
    • Time Frame: Month 0, 6, 12,18,24
    • Change in rate of Emergency Department utilization by participating members.

Participating in This Clinical Trial

Inclusion Criteria

  • Adults age 18 to 65
  • New York State Medicaid Managed Care Members
  • Have utilized emergency department services 6 or more times in a 12-month period
  • Have been assigned to the Pilot Project by their Medicaid Managed Care Plan

Exclusion Criteria

  • Individuals not assigned by a Managed Care Organization meeting the above criteria

Gender Eligibility: All

Minimum Age: 18 Years

Maximum Age: 65 Years

Are Healthy Volunteers Accepted: No

Investigator Details

  • Lead Sponsor
    • Northern New York Rural Behavioral Health Institute
  • Provider of Information About this Clinical Study
    • Sponsor
  • Overall Official(s)
    • Robert Cawley, BBA, Principal Investigator, Northern NY Rural Behavioral Health Institute
  • Overall Contact(s)
    • Barry Brogan, MAPP, 518-891-9460, barry@behaviorhealthnet.orh

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