Health Care Hotspotting: A Randomized Controlled Trial
The Camden Coalition of Healthcare Providers’ Care Management Program, Link2Care, targets “super-utilizers” of the health care system – specifically adults with two or more hospitalizations in the prior six months and multiple chronic conditions – with intensive care-management services in the months following hospital discharge. A team of nurses, social workers, community health workers, and health coaches, supported by real-time data of health care use, perform home visits, accompany patients to doctor visits, and help patients enroll in social-service programs. This approach aims to improve the self-sufficiency of patients in navigating the health care and social-service systems and has the potential to reduce hospital re-admissions and improve patient well-being. This project will rigorously investigate the impacts of the program on subsequent health care utilization and the use of social services through a randomized controlled trial.