This study is looking at ways to improve care for Medicare patients who are at higher risk of being hospitalized. It's testing three different approaches: the Ambulatory Care Coordinator Team (ACCT), where you'd work with various doctors and have access to nurses and social workers for care coordination; the Comprehensive Care Physician Program (CCP), where you'd see one doctor for both inpatient and outpatient care; or the Comprehensive Care Community & Culture Program (C4P), which adds social needs screening, community health worker support, and arts and culture programs to the CCP model. The goal is to see if these programs can reduce how often patients need to be hospitalized. Researchers will also look at how these programs affect your engagement in your care, your satisfaction, and your overall health and mental well-being. To join, you must have Medicare Part A and Part B and have been hospitalized once in the last two years, or be in the emergency department when recruitment starts.

Study design

This is an interventional study, meaning participants will receive a specific intervention. It aims to enroll 3000 participants.

What's involved

Not specified in the trial record.

Compensation

Not stated in the trial record.

Follow-up

Your hospitalization rate will be measured quarterly throughout the study, which can last from 1 to 4.5 years.

AI-generated from the public study record. Only the study team can confirm whether you're eligible — confirm details with them before making decisions.