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| Name | Class |
|---|---|
| Coventry Health Care, Inc. | INDUSTRY |
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The investigators are studying the impact of the interventions of a multidisciplinary team (MDT) - consisting of a Coventry case manager, social worker, and medical director, alongside a Medco specialist pharmacist - on the hospitalization rates of high risk seniors with chronic conditions, compared with a usual care approach. The study will also examine the impact on quality of life, medication adherence, medical costs, hospital readmission rates, and a variety of other important measures. The outcome of COSS may support a means to further enhance and develop a comprehensive care model program by leveraging the partnership between a health plan and a pharmacy benefit manager.
The multidisciplinary team will provide face-to-face visits in a home setting with interventions that focus on five key areas: care transitions, self-management, care coordination, pharmacy and prevention, all designed to support high-risk Medicare members and their relationship with their primary care providers. If the study proves to reduce hospitalizations in the senior population, it could provide important guidance for future efforts to reduce the cost and improve the quality of care for seniors with chronic conditions.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Control Group | Other | The control group will receive usual care as provided by your Health Plan. |
|
| Intervention group | Other | Additional visits will be conducted by a member of the multidisciplinary team (case manager/nurse, social worker and/or pharmacist that will be either face to face or by telephone. |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Multidisciplinary team interventions | Other | The multidisciplinary team will determine which intervention should be applied to the participant in the intervention group based on their health risk assessment responses as well as medication review and visual inspection of the home. |
| Measure | Description | Time Frame |
|---|---|---|
| Determine the impact of multidisciplinary team interventions in reducing the rate of non-elective hospitalizations over a 12 month period compared to usual care | 12 months |
| Measure | Description | Time Frame |
|---|---|---|
| Determine the impact of multidisciplinary team interventions on the rate of emergency room visits not resulting in hospitalization in a 24 hour period or less. | 12 months | |
| Determine the impact of multidisciplinary team interventions versus usual care on health-related quality of life (HR-QOL) |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Julia O McEachern, MHS, PA-C | Medco Health Solutions, Inc. | Principal Investigator |
| Stephen L Cavalieri, MD | Coventry Health Care, Inc. | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Kansas City | Missouri | United States | ||||
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| Multidisciplinary team bimonthly visits either in person or via telephone. | Other |
|
| Usual case management and pharmacy management as provided by the health Plan and the pharmacy benefit manager | Other |
|
| 12 months |
| Determine the impact of MDT interventions versus usual care on inpatient costs associated with non-elective hospital events [rehabilitation, physician, incurred but not reported (IBNR)] | 12 months |
| Determine the impact of multidisciplinary team interventions versus usual care on total outpatient costs (physician, pharmacy,rehabilitation) | 12 months |
| Determine the impact of multidisciplinary team interventions versus usual care on satisfaction with care | 12 months |
| Determine the impact of multidisciplinary team interventions versus usual care on rate of non-elective hospitalizations by chronic condition | 12 months |
| Determine the impact of multidisciplinary team interventions versus usual care on non-elective hospital readmissions at 30, 60, and 90 days following the first non-elective hospitalization event | 12 |
| Determine the impact of multidisciplinary team interventions versus usual care on the length of stay (LOS) of each non-elective hospitalization | 12 months |
| St Louis |
| Missouri |
| United States |
| ID | Term |
|---|---|
| D006333 | Heart Failure |
| D029424 | Pulmonary Disease, Chronic Obstructive |
| D002318 | Cardiovascular Diseases |
| D003920 | Diabetes Mellitus |
| D010024 | Osteoporosis |
| ID | Term |
|---|---|
| D006331 | Heart Diseases |
| D008173 | Lung Diseases, Obstructive |
| D008171 | Lung Diseases |
| D012140 | Respiratory Tract Diseases |
| D002908 | Chronic Disease |
| D020969 | Disease Attributes |
| D010335 | Pathologic Processes |
| D013568 | Pathological Conditions, Signs and Symptoms |
| D044882 | Glucose Metabolism Disorders |
| D008659 | Metabolic Diseases |
| D009750 | Nutritional and Metabolic Diseases |
| D004700 | Endocrine System Diseases |
| D001851 | Bone Diseases, Metabolic |
| D001847 | Bone Diseases |
| D009140 | Musculoskeletal Diseases |
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