Cardiac Condition Clinical Trial
Official title:
Pilot Intervention to Improve the Transition From Hospital to Home
The study had three parts:
Part 1: Patients (or their home caretakers) who live outside of Denver and receive their
primary care at a location other than the Denver VAMC were interviewed after their
discharge. The interview covered the patient's perspective about the transition of their
medical care from the Denver VA to their primary care facility.
Part 2: Primary care providers from the VA facilities that refer patients to the Denver VA
were interviewed regarding their opinions of transition process from the Denver VA back to
the primary care VA facilities.
Part 3: The data from the above interviews were used to develop an intervention to improve
the transition process from the Denver VA back to the primary care VA facilities.
Aim 1 was to describe barriers and facilitators of the transition process from hospital to
home through qualitative interviews among patients discharged from Denver VA Medical Center
(tertiary facility) after being transferred from a primary care VA.
Aim 2 was to describe barriers and facilitators of the transition process through
qualitative interviews among providers at primary care VA facilities who take care of
patients discharged from the Denver VA Medical Center for a cardiac condition.
Aim 3 was to pilot test the transitions of care intervention that targets patients and
providers to evaluate the feasibility of the intervention to improve process of care
measures, including: 1) PCP follow-up within 2-4 weeks of hospital discharge; 2) medications
reconciled between pre and post-hospital discharge; 3) discharge summary available to PCP at
time of visit; and 4) patient awareness of symptoms that require medical attention. This
pilot was informed by the interviews from Aims 1 and 2 and best practices from the
literature. Finally, as part of Aim 3, the primary care providers who saw the patients who
completed the pilot were contacted to ask for their input and feedback regarding the pilot
project.
Description of Enrolled Population: Study Design and Research Methods This was a mixed
methods study where both qualitative and quantitative methods were employed. Through a
series of qualitative interviews (n=26), potential barriers and facilitators of the current
discharge process were assessed in this hub and spoke model of cardiac care. Informed by
these interviews, the transitions of care intervention refined elements from prior studies
that have improved this transition process. Finally, a pilot test of this intervention was
implemented to assess the effectiveness of the intervention to improve important processes
of care during this transition period among patients (n=8) discharged from Denver VAMC after
transfer from a primary care VA facility.
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Allocation: Non-Randomized, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Health Services Research