Recruiting

Observational Study

Sponsor:

Contra Costa Health Services

Code:

NCT04000074

Conditions

Social Determinants of Health

Eligibility Criteria

Sex: All

Age: 18+

Healthy Volunteers: Accepted

Interventions

Telephonic Services

In-Person Services

Study Details

Brief summary:

Contra Costa Health System's WPC Pilot Program, titled Community Connect (CMCT), delivers case management and linkage services to high-risk Medi-Cal members in Contra Costa County, California. This program is funded under the CMS/DHCS 1115 Waiver Whole Person Care (WPC) Pilot Program through 2020. High-risk individuals from the population of Contra Costa County full-scope Medi-Cal enrollees are connected with a case manager who provides linkage services to address their social determinants of health.

Program capacity is below the eligible population, so a tiered randomization strategy is used to identify enrollees and similarly risky controls (who are eligible for enrollment at later intervals). Health behaviors of enrollees and controls are tracked via electronic health records, billing claims, and other social service administrative databases to create a detailed record of post-randomization health behavior. The primary outcome of interest is avoidable utilization of emergency room and in-patient services.

Conditions

Social Determinants of Health

Study ID

NCT04000074

Start date

Jan 1, 2017

Status verified date

Jun, 2019

Completion date

Dec 31, 2021

Anticipated

Primary completion date

Dec 31, 2020

Anticipated

Eligibility Criteria

Eligibility Criteria

Sex: All

Age: 18+

Healthy Volunteers: Accepted

Inclusion Criteria:

  • Full Scope MediCal members administered by Contra Costa Health Services and in Contra Costa Regional Medical Centers network.
  • Having sufficiently high estimated risk of future avoidable utilization to rank within the top 25,000 of the potentially eligible population

Exclusion Criteria:

  • Not case managed under other locally administered plans
  • Not living outside Contra Costa County
  • Not in detention for the past month
  • Not hospitalized for the past month
  • Not previously enrolled in the program (some disenrollment reasons allow for subsequent re-eligibility)

Study Design

Enrollment

60000 participants

Anticipated

Allocation

Randomized

Intervention Model

Sequential

Primary purpose

Health Services Research

Interventions and Outcome Measures

Arms

experimental: Telephonic Services - Intervention

Persons in this group are linked with a telephonic case manager to help address their social needs.

no intervention: Telephonic Services - Control

Persons in this group are similar in risk to those in the 'Telephonic Services - Intervention' arm, but are not linked with a case manager.

experimental: In-Person Services - Intervention

Persons in this group are linked with an in-person case manager who makes home visits to help address their social needs.

no intervention: In-Person Services - Control

Persons in this group are similar in risk to those in the In-Person Services - Intervention' arm, but are not linked with a case manager.

Interventions

Telephonic Services

Provides linkage services to local programs that address the social determinants of health remotely via phone, email and/or fax

In-Person Services

Provides linkage services to local programs that address the social determinants of health directly to the client during face-to-face visits as well as remotely via phone, email, etc.

Primary outcome measure

  • Avoidable Emergency Room Visit Rate [ Time Frame: Controls: From the date of identification to the earlier of 1) Date of subsequent enrollment or 2) End of Study, an average of 1 year Intervention: From the date of enrollment (or first goal) to the date of program disenrollment, average of 1 year. ]
  • Avoidable In-Patient Visit Rate [ Time Frame: Controls: From the date of identification to the earlier of 1) Date of subsequent enrollment or 2) End of Study, an average of 1 year Intervention: From the date of enrollment (or first goal) to the date of program disenrollment, average of 1 year. ]

Central Contacts and Locations

Locations

Contra Costa Whole Person Care Program

Recruiting

Concord, California, United States, 94520

Contacts

Sara Levin, MD

925-608-5102sara.levin@cchealth.org

Daniel M Brown, PhD

925-325-8705daniel.brown@cchealth.org

Principal Investigator:

Sara Levin, MD

More Information

Sponsor

Contra Costa Health Services

Last update posted

Jun 27, 2019

Last verified

Jun, 2019

Keywords

  • Social Determinants of Health
  • High-Needs, High-Cost Populations
  • Case Management
  • Social Prescribing
  • Linkage Services

Trial information was received from ClinicalTrials.gov and was last updated on 2026-09-10. This information was provided to ClinicalTrials.gov by Contra Costa Health Services on 2019-06-27.