Evaluating the Impact of a Supportive Care Program

Overview

NYU's High Risk Program targets patients who may be more likely to have increased hospitalization due to health conditions that may cause death in the near future. Community Health Workers, a home visiting doctor service, a supportive care nurse, and behavioral health specialist engage the population to address a range of biopsychosocial needs with end goal in increasing support in the community and engaging palliative and hospice care when appropriate to prevent hospital readmissions, shorten length of stay, reduce hospital utilization, and decrease overall patient cost with a focus on hospital spend.

Study Type

  • Study Type: Observational
  • Study Design
    • Time Perspective: Prospective
  • Study Primary Completion Date: November 7, 2022

Interventions

  • Behavioral: Supportive care program
    • Community Health Workers, a home visiting doctor service, a supportive care nurse, and behavioral health specialist engage the population to address a range of biopsychosocial needs with end goal in increasing support in the community and engaging palliative and hospice care when appropriate to prevent hospital readmissions, shorten length of stay, reduce hospital utilization, and decrease overall patient cost with a focus on hospital spend.

Arms, Groups and Cohorts

  • HealthFirst Intervention
    • Patients attributed to HealthFirst who will receive the intervention
  • HealthFirst Control
    • Patients attributed to HealthFirst who will not receive the intervention
  • Mortality Model Intervention
    • Patients who are identified as High Risk by the mortality predictive model and who receive the intervention.
  • Mortality Model Control
    • Patients who are identified as High Risk by the mortality predictive model and who do not receive the intervention.

Clinical Trial Outcome Measures

Primary Measures

  • Rate of Advance Care Planning note creation
    • Time Frame: 2 years
    • How many and how often are ACP notes written for patients

Participating in This Clinical Trial

Inclusion Criteria

  • 18 years or older – at or above the 75th percentile on the Mortality Model – Attributed to a value based contract Exclusion Criteria:

  • Less than 18 years of age – Below the 75th percentile on the Mortality Model – Not attributed to a value based contract

Gender Eligibility: All

Minimum Age: 18 Years

Maximum Age: N/A

Investigator Details

  • Lead Sponsor
    • NYU Langone Health
  • Provider of Information About this Clinical Study
    • Sponsor

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