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Improving How Older Adults at Risk for Cardiovascular Outcomes Are Selected for Care Coordination

NCT05820295

CompletedNA

Sponsor: Weill Medical College of Cornell University

Conditions: Cardiovascular Diseases, Myocardial Infarction, Atrial Fibrillation, Diabetes Mellitus, Heart Failure

Interventions: Care coordination delivered based on perceived need, Care coordination delivered based on usual care (e.g. discharge from hospital)

Countries: United States

This pragmatic clinical trial embedded in an accountable care organization will determine the comparative effectiveness of two approaches for assigning care coordinators to older adults at risk for cardiovascular outcomes. The hypothesis is that assigning care coordinators to older adults based on perceived need will be more effective at preventing emergency department visits and hospitalizations compared to usual care.

Eligibility overview

Sex: ALL

Age: 65 Years to —

Healthy volunteers: No

Study type: INTERVENTIONAL

Eligibility criteria

Inclusion Criteria:

* Medicare beneficiaries 65 years and older,
* Attributed to the NewYork Quality Care accountable care organization,
* Are community-dwelling,
* Have cardiovascular disease or 1 or more cardiovascular risk factors, and
* Had highly fragmented ambulatory care in the prior year (defined as a reversed Bice-Boxerman Index greater than or equal to 0.85)

Exclusion Criteria:

* Those who reside in long-term care or nursing home facilities (based on addresses in Medicare claims)
* Enrolled in home hospice
* Dementia (as measured in claims using the Bynum Standard 1-year definition)

Locations (1)

New York, New York, United States