Improving care for disadvantaged Medicare patients to reduce hospitalizations

Care in the Comprehensive Care Physician (CCP) Program vs. Care in the Comprehensive Care Community and Culture Program (C4P) vs. Care in the Traditional Care

Not applicable Interventional University of Chicago · NCT04489693

This study is testing three different ways to provide care for low-income Medicare patients at high risk of going to the hospital to see which one helps them stay healthier and happier.

Quick facts

PhaseNot applicable
Study typeInterventional
Enrollment3000 (estimated)
Ages18 Years and up
SexAll
SponsorUniversity of Chicago Academic / other
Locations1 site (Chicago, Illinois)
Trial IDNCT04489693 on ClinicalTrials.gov

What this trial studies

This randomized trial evaluates the effectiveness of three different care coordination models for socioeconomically disadvantaged Medicare patients at high risk of hospitalization. Participants will receive care through either an Ambulatory Care Coordinator Team (ACCT), a Comprehensive Care Physician Program (CCP), or a Comprehensive Care Community & Culture Program (C4P) that includes additional support for social needs. The study aims to assess the impact of these models on hospitalization rates, patient engagement, satisfaction with care, and overall health outcomes. By addressing both medical and social needs, the trial seeks to provide evidence on effective strategies for reducing health disparities.

Who should consider this trial

Good fit: Ideal candidates are socioeconomically disadvantaged Medicare patients who have been hospitalized at least once in the past two years or are in the emergency department at the time of recruitment.

Not a fit: Patients who do not meet the Medicare eligibility criteria or have not been hospitalized recently may not benefit from this study.

Why it matters

Potential benefit: If successful, this study could lead to reduced hospitalization rates and improved health outcomes for vulnerable Medicare patients.

How similar studies have performed: Other studies have shown promise in improving care coordination for high-risk populations, but this specific approach is relatively novel.

Eligibility criteria

Show full inclusion / exclusion criteria
Inclusion Criteria:

* Must have Medicare Part A and Part B
* Must have been hospitalized once in the past 2 years or be in emergency department at time recruitment is initiated

Exclusion Criteria:

\- None

Where this trial is running

Chicago, Illinois

How to participate

  1. Review the eligibility criteria above with your treating physician.
  2. Visit the official trial page on ClinicalTrials.gov for the most current contact information and recruitment status.
  3. Contact the listed study coordinator or principal investigator to request pre-screening. Pre-screening is free and never obligates you to enroll.
Conditions Comprehensive CareQuality of CareMedicareCost of Care
Last reviewed 2026-06-13 by the Find a Trial editorial team. Information on this page is for educational purposes and is not medical advice. Always consult qualified healthcare professionals about clinical trial participation.