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

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.

This project will use a pragmatic clinical trial embedded in an accountable care organization (ACO) to determine the comparative effectiveness of two different approaches for selecting older adults at risk for cardiovascular outcomes to receive support from care coordinators: (1) an approach that assigns older adults to care coordinators based on self-reported difficulty with care coordination, or (2) usual care, which generally assigns older adults to care coordinators after hospital discharge, regardless of perceived need. The investigators will include community-dwelling Medicare beneficiaries ≥65 years old with cardiovascular disease (CVD) or 1 or more CVD risk factors who have been attributed to the NewYork Quality Care ACO and who have fragmented care. The investigators will randomize the participants into two groups. This study is highly pragmatic, and the intervention is sustainable and scalable. Moreover, the proposed approach has the potential to improve care delivery and outcomes for older adults at risk for cardiovascular outcomes.

Cardiovascular Diseases, Myocardial Infarction, Atrial Fibrillation, Diabetes Mellitus, Heart Failure, Hyperlipidemias, Hypertension, Ischemic Heart Disease, Stroke, Transient Ischemic Attack

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.

Usual care assigns patients to care coordinators in response to a discharge from a hospital or a direct referral from a physician.

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.

If a patient is discharged from a hospital, the patient will be selected for care management services.

Change in the number of self-reported problems with care coordination at 1 month after the start of care coordination compared to baseline

Appropriateness, as measured by the number of care coordination activities in each group, listed by type

The number of care coordination activities in each group (e.g., facilitating provider-provider communication, arranging transportation, etc.)

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)