Ignite Creation Date:
2025-12-24 @ 1:36 PM
Ignite Modification Date:
2025-12-31 @ 6:32 AM
Study NCT ID:
NCT05820295
Status:
COMPLETED
Last Update Posted:
2025-09-04
First Post:
2023-04-07
Is NOT Gene Therapy:
True
Has Adverse Events:
True
Brief Title:
Improving How Older Adults at Risk for Cardiovascular Outcomes Are Selected for Care Coordination
Sponsor:
Organization:
Raw JSON
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Perceived need will be measured through a proxy's responses to a previously validated telephone survey on perceptions of care coordination.\n\nCare coordination delivered based on perceived need: 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.", 'otherNumAtRisk': 202, 'deathsNumAtRisk': 202, 'otherNumAffected': 0, 'seriousNumAtRisk': 202, 'deathsNumAffected': 4, 'seriousNumAffected': 0}, {'id': 'EG001', 'title': 'Control', 'description': 'Usual care assigns patients to care coordinators in response to a discharge from a hospital or a direct referral from a physician.\n\nCare coordination delivered based on usual care (e.g. discharge from hospital): If a patient is discharged from a hospital, the patient will be selected for care management services.', 'otherNumAtRisk': 198, 'deathsNumAtRisk': 198, 'otherNumAffected': 0, 'seriousNumAtRisk': 198, 'deathsNumAffected': 1, 'seriousNumAffected': 0}], 'frequencyThreshold': '0'}, 'outcomeMeasuresModule': {'outcomeMeasures': [{'type': 'PRIMARY', 'title': 'Number of Emergency Department Visits or Hospital Admissions', 'denoms': [{'units': 'Participants', 'counts': [{'value': '202', 'groupId': 'OG000'}, {'value': '198', 'groupId': 'OG001'}]}], 'groups': [{'id': 'OG000', 'title': 'Intervention', 'description': "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.\n\nCare coordination delivered based on perceived need: 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."}, {'id': 'OG001', 'title': 'Control', 'description': 'Usual care assigns patients to care coordinators in response to a discharge from a hospital or a direct referral from a physician.\n\nCare coordination delivered based on usual care (e.g. discharge from hospital): If a patient is discharged from a hospital, the patient will be selected for care management services.'}], 'classes': [{'categories': [{'measurements': [{'value': '0.25', 'groupId': 'OG000', 'lowerLimit': '0.21', 'upperLimit': '0.31'}, {'value': '0.21', 'groupId': 'OG001', 'lowerLimit': '0.17', 'upperLimit': '0.27'}]}]}], 'paramType': 'NUMBER', 'timeFrame': 'Over 12 months (beginning 1 month after the start of care coordination)', 'description': 'Occurrence of an emergency department visit or hospital admission, as measured in Medicare claims. This outcome measure allows more than one event per participant.', 'unitOfMeasure': 'events per 100 person-days alive', 'dispersionType': '95% Confidence Interval', 'reportingStatus': 'POSTED'}, {'type': 'SECONDARY', 'title': 'Acceptability', 'denoms': [{'units': 'Participants', 'counts': [{'value': '202', 'groupId': 'OG000'}, {'value': '198', 'groupId': 'OG001'}]}], 'groups': [{'id': 'OG000', 'title': 'Intervention', 'description': "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.\n\nCare coordination delivered based on perceived need: 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."}, {'id': 'OG001', 'title': 'Control', 'description': 'Usual care assigns patients to care coordinators in response to a discharge from a hospital or a direct referral from a physician.\n\nCare coordination delivered based on usual care (e.g. discharge from hospital): If a patient is discharged from a hospital, the patient will be selected for care management services.'}], 'classes': [{'categories': [{'measurements': [{'value': '13', 'groupId': 'OG000'}, {'value': '17', 'groupId': 'OG001'}]}]}], 'paramType': 'COUNT_OF_PARTICIPANTS', 'timeFrame': 'Up to 1 year of follow-up', 'description': 'Number of people in each group who accept care management', 'unitOfMeasure': 'Participants', 'reportingStatus': 'POSTED'}, {'type': 'SECONDARY', 'title': 'Appropriateness', 'denoms': [{'units': 'Participants', 'counts': [{'value': '13', 'groupId': 'OG000'}, {'value': '17', 'groupId': 'OG001'}]}], 'groups': [{'id': 'OG000', 'title': 'Intervention', 'description': "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.\n\nCare coordination delivered based on perceived need: 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."}, {'id': 'OG001', 'title': 'Control', 'description': 'Usual care assigns patients to care coordinators in response to a discharge from a hospital or a direct referral from a physician.\n\nCare coordination delivered based on usual care (e.g. discharge from hospital): If a patient is discharged from a hospital, the patient will be selected for care management services.'}], 'classes': [{'categories': [{'measurements': [{'value': '13', 'groupId': 'OG000'}, {'value': '17', 'groupId': 'OG001'}]}]}], 'paramType': 'COUNT_OF_PARTICIPANTS', 'timeFrame': 'Up to 1 year of follow-up', 'description': "Number of participants who requested care management services that were in scope for the care managers' credentials", 'unitOfMeasure': 'Participants', 'reportingStatus': 'POSTED', 'populationDescription': 'This outcome is restricted to those who accepted care management.'}, {'type': 'SECONDARY', 'title': 'Fidelity', 'denoms': [{'units': 'Participants', 'counts': [{'value': '13', 'groupId': 'OG000'}, {'value': '17', 'groupId': 'OG001'}]}], 'groups': [{'id': 'OG000', 'title': 'Intervention', 'description': "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.\n\nCare coordination delivered based on perceived need: 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."}, {'id': 'OG001', 'title': 'Control', 'description': 'Usual care assigns patients to care coordinators in response to a discharge from a hospital or a direct referral from a physician.\n\nCare coordination delivered based on usual care (e.g. discharge from hospital): If a patient is discharged from a hospital, the patient will be selected for care management services.'}], 'classes': [{'categories': [{'measurements': [{'value': '13', 'groupId': 'OG000'}, {'value': '17', 'groupId': 'OG001'}]}]}], 'paramType': 'COUNT_OF_PARTICIPANTS', 'timeFrame': 'Up to 1 year of follow-up', 'description': 'Number of participants who received care management services, among those who requested care management services.', 'unitOfMeasure': 'Participants', 'reportingStatus': 'POSTED', 'populationDescription': 'This measure is restricted to those who requested care management services.'}, {'type': 'SECONDARY', 'title': 'Efficiency', 'denoms': [{'units': 'Participants', 'counts': [{'value': '202', 'groupId': 'OG000'}, {'value': '198', 'groupId': 'OG001'}]}], 'groups': [{'id': 'OG000', 'title': 'Intervention', 'description': "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.\n\nCare coordination delivered based on perceived need: 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."}, {'id': 'OG001', 'title': 'Control', 'description': 'Usual care assigns patients to care coordinators in response to a discharge from a hospital or a direct referral from a physician.\n\nCare coordination delivered based on usual care (e.g. discharge from hospital): If a patient is discharged from a hospital, the patient will be selected for care management services.'}], 'classes': [{'categories': [{'measurements': [{'value': '52', 'groupId': 'OG000'}, {'value': '45', 'groupId': 'OG001'}]}]}], 'paramType': 'NUMBER', 'timeFrame': 'Up to 1 year of follow-up', 'description': 'The total number of care management encounters per group. This measure allows more than one encounter per participant.', 'unitOfMeasure': 'Encounters', 'reportingStatus': 'POSTED'}]}, 'participantFlowModule': {'groups': [{'id': 'FG000', 'title': 'Intervention', 'description': "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.\n\nCare coordination delivered based on perceived need: 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."}, {'id': 'FG001', 'title': 'Control', 'description': 'Usual care assigns patients to care coordinators in response to a discharge from a hospital or a direct referral from a physician.\n\nCare coordination delivered based on usual care (e.g. discharge from hospital): If a patient is discharged from a hospital, the patient will be selected for care management services.'}], 'periods': [{'title': 'Overall Study', 'milestones': [{'type': 'STARTED', 'achievements': [{'groupId': 'FG000', 'numSubjects': '202'}, {'groupId': 'FG001', 'numSubjects': '198'}]}, {'type': 'COMPLETED', 'achievements': [{'groupId': 'FG000', 'numSubjects': '202'}, {'groupId': 'FG001', 'numSubjects': '198'}]}, {'type': 'NOT COMPLETED', 'achievements': [{'groupId': 'FG000', 'numSubjects': '0'}, {'groupId': 'FG001', 'numSubjects': '0'}]}]}]}, 'baselineCharacteristicsModule': {'denoms': [{'units': 'Participants', 'counts': [{'value': '202', 'groupId': 'BG000'}, {'value': '198', 'groupId': 'BG001'}, {'value': '400', 'groupId': 'BG002'}]}], 'groups': [{'id': 'BG000', 'title': 'Intervention', 'description': "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.\n\nCare coordination delivered based on perceived need: 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."}, {'id': 'BG001', 'title': 'Control', 'description': 'Usual care assigns patients to care coordinators in response to a discharge from a hospital or a direct referral from a physician.\n\nCare coordination delivered based on usual care (e.g. discharge from hospital): If a patient is discharged from a hospital, the patient will be selected for care management services.'}, {'id': 'BG002', 'title': 'Total', 'description': 'Total of all reporting groups'}], 'measures': [{'title': 'Age, Continuous', 'classes': [{'categories': [{'measurements': [{'value': '76.1', 'spread': '7.1', 'groupId': 'BG000'}, {'value': '75.8', 'spread': '7.0', 'groupId': 'BG001'}, {'value': '75.8', 'spread': '7.0', 'groupId': 'BG002'}]}]}], 'paramType': 'MEAN', 'unitOfMeasure': 'years', 'dispersionType': 'STANDARD_DEVIATION'}, {'title': 'Sex: Female, Male', 'classes': [{'categories': [{'title': 'Female', 'measurements': [{'value': '141', 'groupId': 'BG000'}, {'value': '146', 'groupId': 'BG001'}, {'value': '287', 'groupId': 'BG002'}]}, {'title': 'Male', 'measurements': [{'value': '61', 'groupId': 'BG000'}, {'value': '52', 'groupId': 'BG001'}, {'value': '113', 'groupId': 'BG002'}]}]}], 'paramType': 'COUNT_OF_PARTICIPANTS', 'unitOfMeasure': 'Participants'}, {'title': 'Race/Ethnicity, Customized', 'classes': [{'title': 'White', 'categories': [{'measurements': [{'value': '143', 'groupId': 'BG000'}, {'value': '141', 'groupId': 'BG001'}, {'value': '284', 'groupId': 'BG002'}]}]}, {'title': 'Non-white', 'categories': [{'measurements': [{'value': '59', 'groupId': 'BG000'}, {'value': '57', 'groupId': 'BG001'}, {'value': '116', 'groupId': 'BG002'}]}]}], 'paramType': 'COUNT_OF_PARTICIPANTS', 'unitOfMeasure': 'Participants'}, {'title': 'Enrollment type', 'classes': [{'title': '65 years and older, and dually eligible for Medicaid', 'categories': [{'measurements': [{'value': '69', 'groupId': 'BG000'}, {'value': '67', 'groupId': 'BG001'}, {'value': '136', 'groupId': 'BG002'}]}]}, {'title': '65 years and older, not dually eligible for Medicaid', 'categories': [{'measurements': [{'value': '132', 'groupId': 'BG000'}, {'value': '131', 'groupId': 'BG001'}, {'value': '263', 'groupId': 'BG002'}]}]}, {'title': 'End-stage renal disease', 'categories': [{'measurements': [{'value': '1', 'groupId': 'BG000'}, {'value': '0', 'groupId': 'BG001'}, {'value': '1', 'groupId': 'BG002'}]}]}, {'title': 'Disability', 'categories': [{'measurements': [{'value': '0', 'groupId': 'BG000'}, {'value': '0', 'groupId': 'BG001'}, {'value': '0', 'groupId': 'BG002'}]}]}], 'paramType': 'COUNT_OF_PARTICIPANTS', 'description': 'Reason for enrollment in Medicare', 'unitOfMeasure': 'Participants'}, {'title': 'Co-morbidities', 'classes': [{'title': 'Acute myocardial infarction', 'categories': [{'measurements': [{'value': '0', 'groupId': 'BG000'}, {'value': '3', 'groupId': 'BG001'}, {'value': '3', 'groupId': 'BG002'}]}]}, {'title': 'Atrial fibrillation', 'categories': [{'measurements': [{'value': '19', 'groupId': 'BG000'}, {'value': '28', 'groupId': 'BG001'}, {'value': '47', 'groupId': 'BG002'}]}]}, {'title': 'Chronic kidney disease (not end-stage)', 'categories': [{'measurements': [{'value': '35', 'groupId': 'BG000'}, {'value': '34', 'groupId': 'BG001'}, {'value': '69', 'groupId': 'BG002'}]}]}, {'title': 'Chronic obstructive pulmonary disease and bronchiectasis', 'categories': [{'measurements': [{'value': '19', 'groupId': 'BG000'}, {'value': '37', 'groupId': 'BG001'}, {'value': '56', 'groupId': 'BG002'}]}]}, {'title': 'Colorectal cancer', 'categories': [{'measurements': [{'value': '9', 'groupId': 'BG000'}, {'value': '4', 'groupId': 'BG001'}, {'value': '13', 'groupId': 'BG002'}]}]}, {'title': 'Depression', 'categories': [{'measurements': [{'value': '43', 'groupId': 'BG000'}, {'value': '44', 'groupId': 'BG001'}, {'value': '87', 'groupId': 'BG002'}]}]}, {'title': 'Diabetes', 'categories': [{'measurements': [{'value': '64', 'groupId': 'BG000'}, {'value': '60', 'groupId': 'BG001'}, {'value': '124', 'groupId': 'BG002'}]}]}, {'title': 'Endometrial cancer', 'categories': [{'measurements': [{'value': '2', 'groupId': 'BG000'}, {'value': '6', 'groupId': 'BG001'}, {'value': '8', 'groupId': 'BG002'}]}]}, {'title': 'End-stage renal disease', 'categories': [{'measurements': [{'value': '1', 'groupId': 'BG000'}, {'value': '3', 'groupId': 'BG001'}, {'value': '4', 'groupId': 'BG002'}]}]}, {'title': 'Female or male breast cancer', 'categories': [{'measurements': [{'value': '25', 'groupId': 'BG000'}, {'value': '25', 'groupId': 'BG001'}, {'value': '50', 'groupId': 'BG002'}]}]}, {'title': 'Heart failure', 'categories': [{'measurements': [{'value': '29', 'groupId': 'BG000'}, {'value': '30', 'groupId': 'BG001'}, {'value': '59', 'groupId': 'BG002'}]}]}, {'title': 'Hyperlipidemia', 'categories': [{'measurements': [{'value': '162', 'groupId': 'BG000'}, {'value': '159', 'groupId': 'BG001'}, {'value': '321', 'groupId': 'BG002'}]}]}, {'title': 'Hypertension', 'categories': [{'measurements': [{'value': '154', 'groupId': 'BG000'}, {'value': '143', 'groupId': 'BG001'}, {'value': '297', 'groupId': 'BG002'}]}]}, {'title': 'Ischemic heart disease', 'categories': [{'measurements': [{'value': '71', 'groupId': 'BG000'}, {'value': '82', 'groupId': 'BG001'}, {'value': '153', 'groupId': 'BG002'}]}]}, {'title': 'Lung cancer', 'categories': [{'measurements': [{'value': '7', 'groupId': 'BG000'}, {'value': '4', 'groupId': 'BG001'}, {'value': '11', 'groupId': 'BG002'}]}]}, {'title': 'Prostate cancer', 'categories': [{'measurements': [{'value': '13', 'groupId': 'BG000'}, {'value': '13', 'groupId': 'BG001'}, {'value': '26', 'groupId': 'BG002'}]}]}, {'title': 'Stroke / transient ischemic attack', 'categories': [{'measurements': [{'value': '7', 'groupId': 'BG000'}, {'value': '9', 'groupId': 'BG001'}, {'value': '16', 'groupId': 'BG002'}]}]}], 'paramType': 'COUNT_OF_PARTICIPANTS', 'unitOfMeasure': 'Participants'}]}}, 'documentSection': {'largeDocumentModule': {'largeDocs': [{'date': '2023-04-27', 'size': 253178, 'label': 'Study Protocol and Statistical Analysis Plan', 'hasIcf': False, 'hasSap': True, 'filename': 'Prot_SAP_000.pdf', 'typeAbbrev': 'Prot_SAP', 'uploadDate': '2025-08-07T14:24', 'hasProtocol': True}]}}, 'protocolSection': {'designModule': {'phases': ['NA'], 'studyType': 'INTERVENTIONAL', 'designInfo': {'allocation': 'RANDOMIZED', 'maskingInfo': {'masking': 'NONE'}, 'primaryPurpose': 'HEALTH_SERVICES_RESEARCH', 'interventionModel': 'PARALLEL'}, 'enrollmentInfo': {'type': 'ACTUAL', 'count': 400}}, 'statusModule': {'overallStatus': 'COMPLETED', 'startDateStruct': {'date': '2023-05-17', 'type': 'ACTUAL'}, 'expandedAccessInfo': {'hasExpandedAccess': False}, 'statusVerifiedDate': '2025-08', 'completionDateStruct': {'date': '2024-07-11', 'type': 'ACTUAL'}, 'lastUpdateSubmitDate': '2025-08-14', 'studyFirstSubmitDate': '2023-04-07', 'resultsFirstSubmitDate': '2025-08-14', 'studyFirstSubmitQcDate': '2023-04-07', 'lastUpdatePostDateStruct': {'date': '2025-09-04', 'type': 'ESTIMATED'}, 'resultsFirstSubmitQcDate': '2025-08-14', 'studyFirstPostDateStruct': {'date': '2023-04-19', 'type': 'ACTUAL'}, 'resultsFirstPostDateStruct': {'date': '2025-09-04', 'type': 'ESTIMATED'}, 'primaryCompletionDateStruct': {'date': '2024-05-31', 'type': 'ACTUAL'}}, 'outcomesModule': {'primaryOutcomes': [{'measure': 'Number of Emergency Department Visits or Hospital Admissions', 'timeFrame': 'Over 12 months (beginning 1 month after the start of care coordination)', 'description': 'Occurrence of an emergency department visit or hospital admission, as measured in Medicare claims. This outcome measure allows more than one event per participant.'}], 'secondaryOutcomes': [{'measure': 'Acceptability', 'timeFrame': 'Up to 1 year of follow-up', 'description': 'Number of people in each group who accept care management'}, {'measure': 'Appropriateness', 'timeFrame': 'Up to 1 year of follow-up', 'description': "Number of participants who requested care management services that were in scope for the care managers' credentials"}, {'measure': 'Fidelity', 'timeFrame': 'Up to 1 year of follow-up', 'description': 'Number of participants who received care management services, among those who requested care management services.'}, {'measure': 'Efficiency', 'timeFrame': 'Up to 1 year of follow-up', 'description': 'The total number of care management encounters per group. This measure allows more than one encounter per participant.'}]}, 'oversightModule': {'oversightHasDmc': False, 'isFdaRegulatedDrug': False, 'isFdaRegulatedDevice': False}, 'conditionsModule': {'keywords': ['care coordination', 'accountable care organization'], 'conditions': ['Cardiovascular Diseases', 'Myocardial Infarction', 'Atrial Fibrillation', 'Diabetes Mellitus', 'Heart Failure', 'Hyperlipidemias', 'Hypertension', 'Ischemic Heart Disease', 'Stroke', 'Transient Ischemic Attack']}, 'descriptionModule': {'briefSummary': '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.', 'detailedDescription': '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.'}, 'eligibilityModule': {'sex': 'ALL', 'stdAges': ['OLDER_ADULT'], 'minimumAge': '65 Years', 'healthyVolunteers': False, 'eligibilityCriteria': 'Inclusion Criteria:\n\n* Medicare beneficiaries 65 years and older,\n* Attributed to the NewYork Quality Care accountable care organization,\n* Are community-dwelling,\n* Have cardiovascular disease or 1 or more cardiovascular risk factors, and\n* Had highly fragmented ambulatory care in the prior year (defined as a reversed Bice-Boxerman Index greater than or equal to 0.85)\n\nExclusion Criteria:\n\n* Those who reside in long-term care or nursing home facilities (based on addresses in Medicare claims)\n* Enrolled in home hospice\n* Dementia (as measured in claims using the Bynum Standard 1-year definition)'}, 'identificationModule': {'nctId': 'NCT05820295', 'briefTitle': 'Improving How Older Adults at Risk for Cardiovascular Outcomes Are Selected for Care Coordination', 'organization': {'class': 'OTHER', 'fullName': 'Weill Medical College of Cornell University'}, 'officialTitle': 'Improving How Older Adults at Risk for Cardiovascular Outcomes Are Selected for Care Coordination', 'orgStudyIdInfo': {'id': '22-09025263'}, 'secondaryIdInfos': [{'id': '1K18HS029255-01', 'link': 'https://reporter.nih.gov/quickSearch/1K18HS029255-01', 'type': 'AHRQ'}]}, 'armsInterventionsModule': {'armGroups': [{'type': 'EXPERIMENTAL', 'label': 'Intervention', 'description': "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.", 'interventionNames': ['Behavioral: Care coordination delivered based on perceived need']}, {'type': 'ACTIVE_COMPARATOR', 'label': 'Control', 'description': 'Usual care assigns patients to care coordinators in response to a discharge from a hospital or a direct referral from a physician.', 'interventionNames': ['Behavioral: Care coordination delivered based on usual care (e.g. discharge from hospital)']}], 'interventions': [{'name': 'Care coordination delivered based on perceived need', 'type': 'BEHAVIORAL', 'description': '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.', 'armGroupLabels': ['Intervention']}, {'name': 'Care coordination delivered based on usual care (e.g. discharge from hospital)', 'type': 'BEHAVIORAL', 'description': 'If a patient is discharged from a hospital, the patient will be selected for care management services.', 'armGroupLabels': ['Control']}]}, 'contactsLocationsModule': {'locations': [{'zip': '10065', 'city': 'New York', 'state': 'New York', 'country': 'United States', 'facility': 'New York Presbyterian Hospital - Weill Cornell Medicine', 'geoPoint': {'lat': 40.71427, 'lon': -74.00597}}], 'overallOfficials': [{'name': 'Lisa M Kern, MD, MPH', 'role': 'PRINCIPAL_INVESTIGATOR', 'affiliation': 'Weill Medical College of Cornell University'}]}, 'ipdSharingStatementModule': {'ipdSharing': 'NO'}, 'sponsorCollaboratorsModule': {'leadSponsor': {'name': 'Weill Medical College of Cornell University', 'class': 'OTHER'}, 'collaborators': [{'name': 'Agency for Healthcare Research and Quality (AHRQ)', 'class': 'FED'}], 'responsibleParty': {'type': 'SPONSOR'}}}}