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The CommunityRx system generates patient-centered e-prescriptions for community services (HealtheRx) via an interface between the electronic health records (EHR) and a comprehensive community resource database. Based on a patient's diagnoses, a HealtheRx will be printed automatically at the end of the ambulatory care visit and will provide patients with a customized map and/or list of places in their community that provide health and social services as well as contact information for a local community health worker who can provide limited case management support. The CommunityRx program aims to promote: 1) better healthcare, 2) better health, and 3) lower cost. The purpose of this research is to systematically evaluate the impact of CommunityRx on health outcomes as well as health care service utilization and total cost of care for Medicaid, Medicare and other beneficiaries. The investigators hypothesize that beneficiaries who participate in the CommunityRx intervention will experience better healthcare, better health and lower total cost of care.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Intervention group | Experimental | This group of patients receives the HealtheRx. |
|
| Control group | No Intervention | This group of patients does not receive the HealtheRx |
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| HealtheRx | Behavioral | The HealtheRx is a prescription for community self-care resources. It includes a printed list of self-care resources provided to the patient at an ambulatory visit and tailored based on data from the electronic medical record. |
| Measure | Description | Time Frame |
|---|---|---|
| Change in cost per beneficiary per year | Cost per beneficiary per year | Annual, up to 6 years |
| Measure | Description | Time Frame |
|---|---|---|
| Change in emergency department visit rate | Hospital emergency department visit rate, overall and for patients diagnosed with a) diabetes, b) hypertension, and c) asthma | Every 3 months, up to 72 months |
| Change in HbA1c control |
| Measure | Description | Time Frame |
|---|---|---|
| Change in technical problems with the CommunityRx system (e.g., number of times system does not work properly) | The number of technical problems experienced with the CommunityRx system (e.g., number of times system does not work properly) | Every 3 months, up to 60 months |
| Change in % of eligible patients receiving a HealtheRx |
Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Stacy Lindau, MD, MAPP | University of Chicago | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| University of Chicago | Chicago | Illinois | 60637 | United States |
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Percentage of patients 18-75 years of age with diabetes (type 1 or type 2) who had hemoglobin A1c > 9.0 %.
| Every 3 months, up to 72 months |
| Change in controlling high blood pressure | % of patients >=18 years old with hypertension diagnosis and a most recent BP measure <140/90mg | Every 3 months, up to 72 months |
| Change in body mass index | Percentage of patients overweight or obese (BMI >=25.0 and <30, BMI >=30) | Every 3 months, up to 72 months |
| Change in inpatient admission rate | Average number of in patient admissions per person | Every 3 months, up to 72 months |
| Change in participant satisfaction (percentage of participants reporting they are satisfied with the HealtheRx) | Program participant satisfaction survey, percentage of participants reporting they are satisfied with the HealtheRx | Every 3 months, up to 60 months |
| Change in provider satisfaction ( percent of providers reporting they are satisfied with the HealtheRx system) | Provider satisfaction survey, percent of providers reporting they are satisfied with the HealtheRx system | Every 6 months, up to 60 months |
| Change in rate of participant use of community-based service providers listed on HealtheRx | Program participant survey, percent of participants who report using at least 1 service listed on their HealtheRx | Every 3 months, up to 60 months |
| Change in HealtheRx reach (proportion of the population in the geography who receive at least 1 HealtheRx) | The proportion of the population in the geography who receive at least 1 HealtheRx | Every 3 months, up to 60 months |
| Change in HealtheRx delivery (providers communicate to patients about the HealtheRx) | providers communicate to patients about the HealtheRx | Every 3 months, up to 60 months |
| Change in HealtheRx usefulness (participant survey, the percent of program participants who report that their HealtheRx is useful) | Program participant survey, the percent of program participants who report that their HealtheRx is useful | Every 3 months, up to 60 months |
| Change in HealtheRx Understandability (participant survey, the percent of program participants who report that their HealtheRx is easy to understand) | Program participant survey, the percent of program participants who report that their HealtheRx is easy to understand | Every 3 months, up to 60 months |
| Change in information sharing (participant survey, the percent of program participants who report that they shared information about the HealtheRx with someone else) | Program participant survey, the percent of program participants who report that they shared information about the HealtheRx with someone else | Every 3 months, up to 60 months |
| Change in knowledge about resources (participant survey, the percent of program participants who report that they did not know about some of the places listed on their HealtheRx) | Program participant survey, the percent of program participants who report that they did not know about some of the places listed on their HealtheRx | Every 3 months, up to 60 months |
| Change in provider confidence in serving social needs (Provider satisfaction survey,) | Provider satisfaction survey, the proportion of providers reporting they are confident in their ability to serve their patients social needs | Every 6 months, up to 60 months |
CommunityRx database and electronic medical records, the proportion of eligible patients who receive a HealtheRx |
| Every 3 months, up to 60 months |
| Change in number of places mapped (community organizations, identified in the geographic region) | Number of places, or community organizations, identified in the geographic region | Every year, up to 6 years |
| Change in number of CommunityRx reports delivered (Number of CommunityRx reports created and given to community organizations) | Number of CommunityRx reports created and given to community organizations | Every 3 months, up to 60 months |
| Change in number of times a community health information specialist is contacted (CHIS call tracker) | CHIS call tracker, number of times a program participant contacted a CHIS | Every 3 months, up to 60 months |
| Change in referrals by service type (number of referrals, or number of times a service was listed on a HealtheRx) | CommunityRx database, number of referrals, or number of times a service was listed on a HealtheRx | Every 3 months, up to 60 months |
| Change in services identified (number of services identified as available at community organizations0 | Service level survey, count of number of services identified as available at community organizations | Every 3 months, up to 60 months |