Clinical trialNCT02106221CompletedPhase 3Interventional

Transforming Outcomes for Patients Through Medical Home Evaluation & reDesign

SponsorCare Management PlusEnrollment65,500Health Information TechnologyNurse Based Care Management

View the registry record on ClinicalTrials.gov

Summary

The lay summary the sponsor registered on ClinicalTrials.gov.

The purpose of this study is to support enhancement, implementation, and evaluation of an improved model for delivering improved primary care to high-risk older adults through the use of health IT tools, focusing on issues related to the patient-centered primary care home (PCPCH) and other similar high-value elements that are proposed to improve patient outcomes. During this study, participating clinics will utilize the already-implemented Integrated Care Coordination Information System (ICCIS). Clinic staff will meet with a practice facilitator (monthly and as needed), and will track study activities and submit invoices via ICCIS reporting. These invoices will be used to simulate a shared savings model where clinics will be reimbursed based on their progress and effort towards their goals. Clinics will set and work towards goals that they have chosen. Goals for the control arm are self-selected by the clinics themselves; goals for the invention arm are related to high-value elements (HVE) that have been identified as areas that can improve patient outcomes. These HVE are: 1. Evidence-based Care Management Based on Need 2. Identification of At-Risk Populations 3. Patient Engagement and Alerts Based on Goals 4. Integrated Information for Care Management, especially around Utilization 5. Population Management Tools

clinicaltrials.gov ↗

Investigators

The overall officials registered on this study. Names that resolve to a FindMyKOL profile link to it; the rest are shown as registered.

David A Dorr, MD, MS
Oregon Health and Science University
Principal Investigator
clinicaltrials.gov ↗
Kimberley Gray, BSN
Oregon Health and Science University
Study Chair
clinicaltrials.gov ↗
Marsha Pierre-Jacques Williams, BA
Oregon Health and Science University
Study Chair
clinicaltrials.gov ↗

A profile link is shown only when the registered name resolves to a person record with a confident, namesake-checked match; ambiguous names stay unlinked.

Sites

1 registered facility, with the per-site recruitment status where the registry publishes one. ClinicalTrials.gov does not publish per-site enrollment counts.

United States

Oregon Health & Science University
Portland, Oregon, United States

Site investigator names are published by ClinicalTrials.gov only while a study recruits, so completed studies list sites without them.

Drugs studied

No drug or biological interventions are in our data for this study. It may test a procedure, device or behavioral intervention, or the intervention list isn't in our current snapshot. See the registry record ↗. Why? →

Registration & key dates

Registry attributes as recorded on the ClinicalTrials.gov study record.

Start: 31 Jul 2011
Primary completion: 30 Jun 2014
Completion: 28 Feb 2015
Last update posted: 29 Jul 2015
Registered enrollment: 65,500
Registry id: NCT02106221

clinicaltrials.gov ↗

Source: ClinicalTrials.gov, via the CTTI AACT database, data as of 4 Nov 2026. Registry facts are shown as registered by the study sponsor; FindMyKOL does not interpret them.