In nearby Doylestown, Health Quality Partners (HQP) conducted the longest Center for Medicare and Medicaid Services (CMS) supported clinical trial, testing the impact of nurses on the care of chronically ill adults living in the community. Leveraging the opportunity to explore what matters most to patients and families, scholars from the Center partnered with HQP’s leadership and clinicians to design and conduct research studies focused on patient-centered outcomes.

End of Life Healthcare Utilization Patterns and Costs of Care in Chronically Ill Aging Adults

Team Members:  Connie Ulrich, Kenneth Coburn, Karen Hirschman, Alexandra Hanlon, Sherry Marcantonio, Meredith Mackenzie, Hyejin Kim

Currently, no studies have evaluated the patterns of healthcare utilization and costs within a randomized controlled trial aimed at improving care for chronically ill aging populations. There is reason to believe that factors such as depression, living alone, and loss of a loved one may have a significant impact on resource use and overall costs. The goal of this project is to develop a predictive model that identifies a parsimonious set of predictors of higher costs of care at end of life. Our data will identify the driving factors that impact healthcare utilization patterns and costs of care at end of life. This data will support future research targeted at developing interventions that promote patient-centered goals and preferences while reducing avoidable healthcare utilization and decreasing costs of care.

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Do Unique Clinical Risk Profiles Predict Hospitalization Among Community-Dwelling Older Adults?

Team Members:  Melissa O’Connor, Sherry Marcantonio, Salimah Meghani, Janet Van Cleave, Joan Davitt, Barbara Riegel, Olga Jarrin, Kathryn Bowles, Sherry Greenberg, Alexandra Hanlon, Ruth Masterson Creber, Mary Naylor, Maxim Topaz, Dexia Kong, Kenneth Coburn

Preventing “avoidable hospitalizations” is a national health care priority. Such adverse events result in unnecessary costs for payers, therefore leaving older adults at risk for unfavorable events during and after the hospital admission. Such risks include, reduced functional status and quality of life and increased risk for death. The long-term goal of this study is to better understand which sets of risk factors identify patients at high-risk for adverse outcomes and avoidable hospitalizations. The proposed research is relevant to public health because the discovery of demographic and clinical risk factors predicting risk for adverse outcomes among community-dwelling older adults will permit better targeting of services to prevent adverse outcomes (hospitalization, emergency department use and death). The proposed research is significant, because it is expected to expand understanding of which community-dwelling older adults are at greater risk for adverse outcomes. Ultimately, such knowledge has the potential to inform the development of community-based interventions that will help to improve the quality of care and improve outcomes among community-dwelling older adults in the United States.

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Nursing Contact and Patient Engagement in a Community-based Care Management Model

Team Members:  Helene Moriarty, Mark Toles, Sherry Marcantonio, Connie Ulrich, Alexandra Hanlon, Darina Molkina, Justine Sefcik, Megan Streur, Kenneth Coburn

Patient engagement signifies participation in “actions individuals must take to obtain the greatest benefit from health care services available to them.” Previous research demonstrates that patients with more engagement have better health outcomes. However, we know very little about strategies that could be used to sustain patient engagement. The proposed innovative study examines the role of nursing contact, provided through a care coordination program, in enhancing patient engagement. We will specifically look at nursing contact provided through HQP’s care coordination program, describing patterns of nursing contact (frequency, type of contact, hours of contact, and nurse continuity) with older adult participants and their family caregivers as it occurred over time. We will also determine the relationship between nursing contact with older adults (and their family caregivers) and patient engagement, as measured by continued enrollment in the care coordination program. In addition, we will describe patients’ perceptions of their experiences, using focus groups. The knowledge gained from this study will provide a deeper understanding of how nursing contact influences patient engagement in health care. This new knowledge may be used to develop and strengthen programs designed to increase patient engagement in health care and ultimately improve patient outcomes.

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The Role of Patient Engagement and Nursing Contact on Health Outcomes in a Community-Based Care Coordination Model

Team Members:  Melissa O’Connor (PI), Helene Moriarty, Tamara Kear, Alexandra Hanlon, Sherry Marcantonio, Ken Coburn

Patient engagement signifies “actions individuals must take to obtain the greatest benefit from the health care services available to them.” Patients with more engagement take a more active role in seeking health care, in making treatment decisions, and in managing their health and illness. Higher patient engagement has been linked to better health outcomes among the chronically ill, but has not been tested among chronically ill older adults who are participating in a community-based care coordination model. The study team will examine the impact of self-reported engagement and patterns of nursing contact on health utilization outcomes over time. Findings gained from this effort will be used to develop and refine ways that will increase older adults’ engagement in their health care, and will also inform future intervention studies designed to support older adults and their families, minimize burden from chronic illness (often resulting in multiple transitions), and ultimately reduce health care costs.