| Primary | Number of Emergency Department Visits or Hospital Admissions | Occurrence of an emergency department visit or hospital admission, as measured in Medicare claims. This outcome measure allows more than one event per participant. | | Posted | | Number | 95% Confidence Interval | events per 100 person-days alive | | Over 12 months (beginning 1 month after the start of care coordination) | | | | ID | Title | Description |
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| OG000 | Intervention | The intervention group will assign care coordinators to individuals based on perceived need for assistance with care coordination. Perceived need will be measured through a proxy's responses to a previously validated telephone survey on perceptions of care coordination. Care coordination delivered based on perceived need: If patients in intervention group report on the survey that they experience difficulty coordinating care among their providers, the patient will be selected for care management services. Those services will attempt to address the problems with care coordination that the proxy reported. | | OG001 | Control | Usual care assigns patients to care coordinators in response to a discharge from a hospital or a direct referral from a physician. Care coordination delivered based on usual care (e.g. discharge from hospital): If a patient is discharged from a hospital, the patient will be selected for care management services. |
| | | Title | Denominators | Categories |
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| | | Title | Measurements |
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| - OG0000.25(0.21 to 0.31)
- OG0010.21(0.17 to 0.27)
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| Secondary | Acceptability | Number of people in each group who accept care management | | Posted | | Count of Participants | | Participants | | Up to 1 year of follow-up | | | | ID | Title | Description |
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| OG000 | Intervention | The intervention group will assign care coordinators to individuals based on perceived need for assistance with care coordination. Perceived need will be measured through a proxy's responses to a previously validated telephone survey on perceptions of care coordination. Care coordination delivered based on perceived need: If patients in intervention group report on the survey that they experience difficulty coordinating care among their providers, the patient will be selected for care management services. Those services will attempt to address the problems with care coordination that the proxy reported. | | OG001 | Control | Usual care assigns patients to care coordinators in response to a discharge from a hospital or a direct referral from a physician. Care coordination delivered based on usual care (e.g. discharge from hospital): If a patient is discharged from a hospital, the patient will be selected for care management services. |
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| Secondary | Appropriateness | Number of participants who requested care management services that were in scope for the care managers' credentials | This outcome is restricted to those who accepted care management. | Posted | | Count of Participants | | Participants | | Up to 1 year of follow-up | | | | ID | Title | Description |
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| OG000 | Intervention | The intervention group will assign care coordinators to individuals based on perceived need for assistance with care coordination. Perceived need will be measured through a proxy's responses to a previously validated telephone survey on perceptions of care coordination. Care coordination delivered based on perceived need: If patients in intervention group report on the survey that they experience difficulty coordinating care among their providers, the patient will be selected for care management services. Those services will attempt to address the problems with care coordination that the proxy reported. | | OG001 | Control | Usual care assigns patients to care coordinators in response to a discharge from a hospital or a direct referral from a physician. Care coordination delivered based on usual care (e.g. discharge from hospital): If a patient is discharged from a hospital, the patient will be selected for care management services. |
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| Secondary | Fidelity | Number of participants who received care management services, among those who requested care management services. | This measure is restricted to those who requested care management services. | Posted | | Count of Participants | | Participants | | Up to 1 year of follow-up | | | | ID | Title | Description |
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| OG000 | Intervention | The intervention group will assign care coordinators to individuals based on perceived need for assistance with care coordination. Perceived need will be measured through a proxy's responses to a previously validated telephone survey on perceptions of care coordination. Care coordination delivered based on perceived need: If patients in intervention group report on the survey that they experience difficulty coordinating care among their providers, the patient will be selected for care management services. Those services will attempt to address the problems with care coordination that the proxy reported. | | OG001 | Control | Usual care assigns patients to care coordinators in response to a discharge from a hospital or a direct referral from a physician. Care coordination delivered based on usual care (e.g. discharge from hospital): If a patient is discharged from a hospital, the patient will be selected for care management services. |
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| Secondary | Efficiency | The total number of care management encounters per group. This measure allows more than one encounter per participant. | | Posted | | Number | | Encounters | | Up to 1 year of follow-up | | | | ID | Title | Description |
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| OG000 | Intervention | The intervention group will assign care coordinators to individuals based on perceived need for assistance with care coordination. Perceived need will be measured through a proxy's responses to a previously validated telephone survey on perceptions of care coordination. Care coordination delivered based on perceived need: If patients in intervention group report on the survey that they experience difficulty coordinating care among their providers, the patient will be selected for care management services. Those services will attempt to address the problems with care coordination that the proxy reported. | | OG001 | Control | Usual care assigns patients to care coordinators in response to a discharge from a hospital or a direct referral from a physician. Care coordination delivered based on usual care (e.g. discharge from hospital): If a patient is discharged from a hospital, the patient will be selected for care management services. |
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