Older adults who are dually eligible for Medicare and Medicaid are among the sickest and poorest individuals covered in either program. Although they have a significantly higher prevalence of chronic conditions, such as heart failure (HF) than all other Medicare beneficiaries, as few as 2% of dual eligible patients receive the type of case management or care coordination that can prevent hospitalizations and emergency department visits for acute medical problems. African-Americans are particularly at risk, having the highest rates of HF-related hospitalizations compared to all other Medicare beneficiaries. In this Phase I SBIR, we will conduct a pilot clinical trial to test a care coordination program designed for African-American dual eligible older adults with HF who have been discharged from a regional hospital and who are being cared for by community-based health care providers. The proposed Mobile Heart Care Coordination (MHCC) program integrates telemonitoring through a Bluetooth-enabled device and mobile phone-based communication technologies that connect hospital-based cardiac care teams with community-based providers. The goal of the program is to provide coordinated post-discharge care in order to reduce potentially-avoidable hospitalizations and emergency room visits. This Phase I SBIR will develop and test the MHCC intervention's feasibility and short-term outcomes for dual eligible African-Americans with HF. In a Phase II application, we will conduct a randomized clinical trial with African-American dual-eligible older adults with HF to determine whether participants in the MHCC- enhanced program are less likely to be readmitted within 30 days of hospital discharge (primary hypothesis) and less likely to access emergency room care (secondary hypothesis) compared to the comparison group (usual care). The Phase I application will provide the necessary data to determine the sample size required for the larger adequately powered randomized controlled trial in Phase II. The subsequent Phase II application will result in an innovative, cost-effective, and nationally replicable care coordination model aimed at reducing potentially-avoidable hospitalizations and emergency room visits, and improving quality of care for all African- American dual eligible patients with HF.
The proposed Phase I intervention tests a culturally tailored, community-based, low cost intervention that relies on telemonitoring and communication technologies to improve care coordination and reduce potentially- avoidable costly hospitalizations and emergency room visits for African-American dual eligibles with heart failure. If successful, this intervention offers a cost-effective model for significantly reducing health disparities among nearly 200,000 African-American dual eligibles with heart failure nationwide as well as other older adult African Americans with HF.