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Currently, UCLA Health (specifically the Office of Population Health and Accountable Care, or OPHAC) runs a complex care management program called Proactive Care (goal is to reduce care utilization by providing personalized care navigation/case management). Every month, an AI Population Risk tool runs to identify around 250 of the 480,000 or so UCLA primary care patients, and RNs contact these 250 patients to enroll in Proactive Care. Starting in December 2024, OPHAC launched a new method of enrolling UCLA's Medicare Advantage (MA) patients into Proactive Care: an AI Cost Prediction model. The idea is the same-- the top 250 highest predicted cost patients will be enrolled in Proactive Care. The investigators will evaluate this model and subsequent enrollment into the program by randomizing the waitlist of MA patients waiting to enroll in Proactive Care, thereby creating a control group. The top 500 highest predicted cost patients will be identified each month, and following a 1:1 randomization, 250 will be contacted for enrollment and the rest will be put on a wait-list control group for 10 months unless otherwise requested by their provider to be enrolled in the Proactive Care program earlier.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Complex Care Management | Active Comparator | Patients randomized to be contacted for enrollment into the complex care management program called ProActive Care. |
|
| Care as usual | No Intervention | Patient randomized to be put on a waitlist for being contacted for enrollment into ProActive Care (ie, not enrolled in ProActive Care). |
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Complex care management program | Behavioral | Intensive outpatient care management program that includes contact from nurses and case managers to help coordinate care, detect clinical red flags, and reduce overall unplanned acute care utilization. |
| Measure | Description | Time Frame |
|---|---|---|
| Days alive and out of hospital (DAOH) at 120 days from randomization | The sum of the number of days that a patient is not hospitalized under inpatient or observation status, and alive, out of a maximum of 120 days post-randomization. | 120 days after randomization |
| Measure | Description | Time Frame |
|---|---|---|
| Days alive and out of hospital (DAOH) at 30 days from randomization | The sum of the number of days that a patient is not hospitalized under inpatient or observation status, and alive, out of a maximum of 30 days post-randomization. | 30 days after randomization |
| Days alive and out of hospital (DAOH) at 90 days from randomization |
| Measure | Description | Time Frame |
|---|---|---|
| Cost prediction model performance over 22 months, as measured by area under the receiver operating characteristic curve | Observed healthcare expenditures for each month's control cohort will be measured over the subsequent 12 months after randomization (ie, 10 months of enrollment + 12 months of follow-up= 22 months), and compared to model-predicted healthcare expenditures. This analysis will only be conducted in the control group, as the intervention is designed to affect healthcare expenditures in the treatment group. |
Inclusion Criteria:
Exclusion Criteria:
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| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Richard K Leuchter, MD | Contact | 310-267-9111 | rleuchter@mednet.ucla.edu | |
| William Turner, BA | Contact | 310-267-9111 | wturner@mednet.ucla.edu |
| Name | Affiliation | Role |
|---|---|---|
| Richard K Leuchter, MD | University of California, Los Angeles | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| UCLA Health | Recruiting | Los Angeles | California | 90095 | United States |
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| Type | Includes Protocol | Includes SAP | Includes ICF | Document Label | Document Date | Document Uploaded Date | Document File Name |
|---|---|---|---|---|---|---|---|
| SAP | No | Yes | No | Statistical Analysis Plan | Mar 31, 2025 | Mar 31, 2025 | SAP_000.pdf |
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| ID | Term |
|---|---|
| D002908 | Chronic Disease |
| ID | Term |
|---|---|
| D020969 | Disease Attributes |
| D010335 | Pathologic Processes |
| D013568 | Pathological Conditions, Signs and Symptoms |
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The sum of the number of days that a patient is not hospitalized under inpatient or observation status, and alive, out of a maximum of 90 days post-randomization. |
| 90 days after randomization |
| Days alive and out of hospital (DAOH) at 10 months from randomization | The sum of the number of days that a patient is not hospitalized under inpatient or observation status, and alive, out of a maximum of 300 days post-randomization. | 10 months post-randomization |
| Total healthcare expenditures at 10 months from randomization | The sum of all healthcare expenditures (inpatient, outpatient, prescription, etc.) as determined by claims data. | 10 months post-randomization |
| All-cause hospitalizations at 10 months from randomization | The total number of hospitalizations under inpatient or observation status for any cause | 10 months post-randomization |
| All-cause emergency department visits at 10 months from randomization | The total number of emergency department visits that did not result in hospitalization, for any cause. | 10 months post-randomization |
| All-cause mortality at 10 months from randomization | The total number of deaths from any cause | 10 months post-randomization |
| Ambulator contact days | The number of days a patient spends outside the home receiving health care, defined as the total number of days with a primary care or specialty care office visit, test, imaging, procedure, or treatment | 10 months post-randomization |
| 12 months after the final cohort enrolls |
| Protocol fidelity over the 10 months of enrollment | The sum of two metrics:
| 14 months post-randomization |
| Avoidable hospitalizations | The number of hospitalizations that could have been avoided through timely access to ambulatory care | 10 months post-randomization |
| Avoidable emergency department visits | The number of emergency department visits that could have been avoided through timely access to ambulatory care | 10 months post-randomization |