A Randomised Control Trial of a Transitional Care Model in Singapore General Hospital

Chronic Diseases Clinical Trial

Official title:

A Randomised Control Trial of a Transitional Care Model in Singapore General Hospital

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT02351648
• Other study ID #: 2012/848/E
• Status: Completed
• Phase: N/A
• First received: January 21, 2015
• Last updated: January 29, 2015
• Start date: October 2012
• Est. completion date: December 2014

Study information

• Verified date: January 2015
• Source: Singapore General Hospital
• Contact: n/a
• Is FDA regulated: No
• Health authority: Singapore: Institutional Review Board
• Study type: Interventional

Clinical Trial Summary

To find out if a transitional care model can reduce the rate of unscheduled readmission to the Department of Internal Medicine (DIM) in SGH

Description:

Hospital with high readmission rate is view as having lower quality of care High readmission rate is view as wasteful healthcare spending

Primary Aim:

To find out if a transitional care model can reduce the rate of unscheduled readmission to the Department of Internal Medicine (DIM) in SGH A readmission episode is defined as an episode of readmission to any tertiary hospital within 30 days after index discharge from SGH

Secondary Aim:

To find out if a transitional care model can reduce the number of visits to the emergency department in SGH To find out the quality of our transitional care model by using a care transition measure (CTM-15)

Recruitment information / eligibility

• Status: Completed
• Enrollment: 840
• Est. completion date: December 2014
• Est. primary completion date: December 2014
• Accepts healthy volunteers: No
• Gender: Both
• Age group: 21 Years and older

Eligibility

Inclusion criteria

-More than 1 admission in the last 90 days

Exclusion Criteria

• Subject is a non-resident

• Subject has no local home address

• Subject is from a long-term care facility during index admission

• Subject is unable to participate in telephone surveillance

• Subject is discharged before takeover

• Subject has impaired decision making capacity without surrogate decision maker

• Subject is pending or currently in critical care unit

• Subject or caregiver is mentally unstable

• Subject is haemodynamically unstable

• Subject requires acute inpatient respiratory support

• Subject requires acute inpatient dialysis support

• Subject pending surgical intervention

• Subject pending transfer to other specialist discipline

• Primary team consultant declined to participate in this research

Study Design

Allocation: Randomized, Intervention Model: Parallel Assignment, Masking: Single Blind (Outcomes Assessor), Primary Purpose: Health Services Research

Related Conditions & MeSH terms

• Chronic Disease
• Chronic Diseases

Intervention

Other:
• a transitional care model
Intervention extend from transfer of care to the study team from the initial admission medical team through 90 days after discharge Intervention in hospital includes the following. Comprehensive discharge planning based on the 6 principles. Discharge planning initially within 24 hours of recruitment Daily ward review of patients Weekly multi-disciplinary meeting Consolidation of medication and follow-up appointment before discharge Assessment of needs before discharge Comprehensive discharge summary and medication record at discharge Intervention after discharge: Work done mainly by integrated care nurse Review of patients within 48 hours after discharge via home visit or phone call Subsequent home visit as needed based on patient's needs At least weekly contact with pt or caregiver via telephone Telephone availability working weekday 8 AM to 5 PM Multi-disciplinary meeting for problematic cases Use chronic disease pathway for suitable patients
• Control
Patients receive usual standard of care from the internal medicine team

Locations

Country	Name	City	State
Singapore	Singapore General Hospital	Singapore

Sponsors (3)

Lead Sponsor	Collaborator
Singapore General Hospital	Agency for Integrated Care, Singapore, Duke-NUS Graduate Medical School

Country where clinical trial is conducted

Singapore, 

References & Publications (3)

Coleman EA, Smith JD, Frank JC, Eilertsen TB, Thiare JN, Kramer AM. Development and testing of a measure designed to assess the quality of care transitions. Int J Integr Care. 2002;2:e02. Epub 2002 Jun 1. — View Citation

Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003 Feb 4;138(3):161-7. — View Citation

Mistiaen P, Poot E. Telephone follow-up, initiated by a hospital-based health professional, for postdischarge problems in patients discharged from hospital to home. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD004510. Review. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Readmission rate	A readmission episode is defined as an episode of readmission to any tertiary hospital within 30 days after index discharge from SGH Readmission rate is calculated by dividing the total number of admission by the total number of patients	30 days after index discharge	No
Secondary	Readmission rate	Readmission rate is calculated by dividing the total number of admission by the total number of patients. This will measured at 7 days, 90 days and 180 days of discharge	up to 180 days after index discharge	No
Secondary	Quality of transitional care using a validated care transition measure (CTM-15) tool	Care transition measure survey of subjects	90 days after index discharge	No
Secondary	Emergency department attendance rate	Emergency department attendance rate is calculated by dividing the total number of emergency department visits by the total number of patients. This will measured at 7 days, 30 days, 90 days and 180 days of discharge	Up to 180 days after index discharge	No
Secondary	Time to first readmission	Censored time to readmission for both intervention and control group	Up to 90 days after index discharge	No
Secondary	Specialist Outpatient Clinic visits	Outpatient clinic visit rate is calculated by dividing the total number of outpatient clinic visits by the total number of patients. This will measured at 90 days and 180 days of discharge	Up to 180 days after index discharge	No