This study explored the potential to improve clinical outcomes in patients at risk of moving to the top segment of the cost acuity pyramid. This randomized controlled trial evaluated the impact of a Stepped-Care approach (predictive analytics + tailored nurse-driven interventions) on healthcare utilization among 370 older adult patients enrolled in a homecare management program and using a Personal Emergency Response System. The Control group (CG) received care as usual, while the Intervention group (IG) received Stepped-Care during a 180-day intervention period. The primary outcome, decrease in emergency encounters, was not statistically significant (15%, p = 0.291). However, compared to the CG, the IG had significant reductions in total 90-day readmissions (68%, p = 0.007), patients with 90-day readmissions (76%, p = 0.011), total 180-day readmissions (53%, p = 0.020), and EMS encounters (49%, p = 0.006). Predictive analytics combined with tailored interventions could potentially improve clinical outcomes in older adults, supporting population health management in home or community settings.

这项研究探讨了改善有可能进入成本敏锐度金字塔顶端部分风险的患者临床结果的潜力。这项随机对照试验评估了分级护理方法（预测分析 + 定制的护士驱动干预措施）对参加家庭护理管理计划并使用个人紧急响应系统的 370 名老年患者的医疗保健利用率的影响。对照组 (CG) 照常接受护理，而干预组 (IG) 在 180 天的干预期内接受阶梯式护理。主要结果是紧急情况减少，但没有统计学意义（15%， p = 0.291）。然而，与 CG 相比，IG 显着减少了 90 天再入院总数 (68%， p = 0.007)、90 天再入院患者总数 (76%， p = 0.011)、180 天再入院总数 (53%) ， p = 0.020）和 EMS 遭遇（49%， p = 0.006）。预测分析与定制干预措施相结合可能会改善老年人的临床结果，支持家庭或社区环境中的人口健康管理。