Care Transitions for Complex Patient - Cycle 1 and Cycle 2
Asthma, Coronary Artery Disease, Diabetes
About this trial
This is an interventional health services research trial for Asthma focused on measuring Complex patients, Care transitions, Patient safety, Patient care, Health Information Technology, Health Information Exchange, Clinical Decision Support, Care coordination, Data sharing
Eligibility Criteria
Inclusion Criteria:
- North Carolina Medicaid beneficiary enrolled in the Northern Piedmont Community Care Network (NPCCN)
- Has complex healthcare needs as defined by having two or more IOM (Institute of Medicine) priority conditions (hypertension, coronary artery disease, congestive heart failure, stroke, asthma, diabetes) OR one of the following: moderate to severe mental health diagnosis (schizophrenic disorder, episodic mood disorder, delusional disorder, non-organic psychosis, anxiety, dissociative-somatoform disorder, personality disorder), end-stage renal disease, sickle cell disease
- Continuous enrollment in NPCCN for 10 of the previous 12 months
Sites / Locations
- Duke University Medical Center (Division of Clinical Informatics)
Arms of the Study
Arm 1
Arm 2
Arm 3
Experimental
Experimental
Experimental
Intermediate Intervention (arm #1)
Full Intervention (arm #2)
Control (arm #3)
Care transition reports sent to primary care clinics, care transition letters sent to patients, release of information requests about care transitions sent on behalf of primary care clinics.
E-mail notices sent to care managers about care transitions plus care transition reports sent to primary care clinics, care transition reports sent to patients, release of information requests about care transitions sent on behalf of primary care clinics.
Subjects assigned to the control group will receive "usual care" which is the standard of care coordination currently existent between patients, providers and care managers.