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New care model aims to keep High-Risk patients out of the hospital

NCT ID NCT07587073

Disease control Sponsor: StratiHealth Source: ClinicalTrials.gov ↗

What the study statuses mean

This study's is highlighted.

Recruitment status, easiest to join first

Recruiting now
This trial is taking on new participants right now.
Not yet recruiting This study
Registered, but not yet taking participants.
By invitation only
Not open to general applications. Only people the study team invites can take part.
Paused
Paused for now. It may or may not start again.
Ongoing
Running, but no longer taking on new participants.
Completed
The trial has finished. Results may not be published yet.
Stopped early
Stopped early, before it reached the end. That can be for many reasons, including safety.
Cancelled
Cancelled before anyone took part.

Expanded access (not trials)

Expanded access
Not a trial. This treatment can be requested outside a study, case by case, for people who qualify.
Expanded access (paused)
Not a trial. The treatment can normally be requested outside a study, but is unavailable right now.
Expanded access (ended)
Not a trial. The treatment could once be requested outside a study, but no longer can.
Approved
The treatment has been approved, so it is available normally rather than through this programme.

When the status isn't known

Details not published
The full record has not been published yet, so there is little to show here.
Status unknown
This status has not been confirmed recently, so it may be out of date.

First seen Jun 25, 2026 · Last updated Jun 27, 2026 · Updated 1 time

Summary

This study tests a comprehensive care bundle for high-risk Medi-Cal members in California. The program includes enhanced care management, community supports, and transitional care to help patients after hospital discharge. Researchers will compare outcomes like hospital readmissions and emergency visits between those receiving the bundle and those getting usual care.

What this could mean

Our plain-language read of the trial. This is informational only, not medical advice or a prediction.

Active substance
care coordination bundle (enhanced care management, community supports, transitional care, residential care coordination)
What this could lead to
If successful, this could show that coordinated care helps high-risk patients avoid unnecessary hospital stays and live more stably in the community.
What could go wrong
This is a pragmatic trial testing a service model, not a new drug. Results may vary across different health plans and regions, and the intervention may not work for everyone.

This is an AI summary of the original study and may miss details. Read our disclaimer.

Study facts

What this study's own registry entry says, in plain language.

Phase

Not a phased trial

Phase numbers describe drug development. The registry uses this when they do not apply, as it does for trials of devices, procedures or behaviour changes, and for observational studies.

Participants

About 1,200 people

The number the study aims to enrol. It can still change while the study runs.

Expected to start

Oct 2026

An estimate. Start dates often move.

Expected to finish

Dec 2028

An estimate. End dates often move.

Lead sponsor

A company

The lead sponsor is a pharmaceutical, biotech, or medical-device company.

Who can take part

This study's own entry requirements. Only the study team can say for certain whether you qualify.

Ages

18 years and older

Sex

Anyone

Healthy volunteers

Not accepted

This study is not open to healthy volunteers. The entry requirements below say who it is open to.

Show the full entry requirements

Copied word for word from the study's registry entry, so the wording is the study team's rather than ours.

Inclusion Criteria: * Adult Medi-Cal managed care member in California. * Identified as high-risk for poor outcomes based on plan stratification or qualifying CalAIM criteria. * Eligible for ECM and at least one of the following: Transitional Care Services, Community Supports related to post-acute recovery, housing/residential stabilization, or nursing facility transition/diversion. * Recent discharge or active transition from hospital, emergency department, skilled nursing facility, post-acute facility, recuperative care, assisted living, residential behavioral health setting, or other qualifying level-of-care transition. * Able to provide informed consent, or eligible for waiver/alteration of consent if approved for cluster-level pragmatic implementation research. Exclusion Criteria: * Enrollment in hospice or expected survival less than 6 months at the time of the index episode. * Long-term custodial institutional placement without an anticipated community transition plan. * Current incarceration or detention is preventing intervention delivery. * Previous enrollment in this study during the same observation window. * Any condition that, in the investigator's judgment, makes participation infeasible or data interpretation unreliable.

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As listed by the trial registrant

The condition terms exactly as the trial's registrant entered them.

Care transitions Complex care Housing instability Population health management Post-acute care utilization Residential care transition

How to take part

Only the study team decides who joins. These are the ways to reach them.

  1. The places running it

    1 site. The list below names each one and where it is.

  2. The official record

    The full official record for this study. This one lists no contact details, but it is the first place any would appear.

    Open the record ↗

  3. A doctor treating you

    A doctor who knows your case can contact a study site on your behalf, and can tell you whether this study is worth pursuing at all.

Contacts and locations

Locations

  • StratiHealth

    Los Angeles, California, 90001, United States

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