PATient Navigator to rEduce Readmissions

Heart Failure Clinical Trial

— PArTNER  

Official title:

PATient Navigator to rEduce Readmissions

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT02114515
• Other study ID #: PCORI-IH 1211-4365
• Status: Completed
• Phase: N/A
• Start date: July 2014
• Est. completion date: October 2016

Study information

• Verified date: October 2018
• Source: University of Illinois at Chicago
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Staying out of the hospital is valued by patients and their caregivers. Their interests converge with those of hospitals now that high 30-day readmission rates for some conditions place hospitals at risk for financial penalties from the Centers for Medicare and Medicaid Services. This study focuses on developing and testing a program that combines a community health worker (lay patient advocate, acting as a "Patient Navigator") and a peer-led telephone support line to improve patient experience during hospital to home transition.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 1029
• Est. completion date: October 2016
• Est. primary completion date: October 2016
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

1. Age 18 years or older on date of hospital admission

2. Hospitalized at the University of Illinois Hospital, Chicago

3. Admission diagnosis, per treating physician, of pneumonia, COPD, sickle cell disease, heart failure, or myocardial infarction

4. Receive medical care on an inpatient medical service

Exclusion Criteria:

1. Unable to understand and speak English

2. Unable/decline to give informed consent

3. Previous participant in PArTNER

4. Planned transfer to another acute care facility

5. Planned discharge to facility other than home (e.g. long term care facility)

6. Currently on hospice or plans to discharge home to hospice

7. Current plans to leave against medical advice

Related Conditions & MeSH terms

• Anemia, Sickle Cell
• Chronic Obstructive Pulmonary Disease
• Heart Failure
• Infarction
• Lung Diseases
• Lung Diseases, Obstructive
• Myocardial Infarction
• Pneumonia
• Pulmonary Disease, Chronic Obstructive
• Sickle Cell Disease

Intervention

Behavioral:
• Hospital usual care
Written discharge instructions provided to patients prior to hospital discharge.
• Navigator intervention
A Patient Navigator will provide social support, literacy appropriate education, and act as a conduit between the patient and the patient's medical team
• Peer-led telephone support line
The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Locations

Country	Name	City	State
United States	University of Illinois Hospital	Chicago	Illinois

Sponsors (14)

Lead Sponsor

Collaborator

University of Illinois at Chicago

AcademyHealth, American Heart Association, Baystate Medical Center, COPD Foundation, Mended Hearts, National Jewish Health, Patient-Centered Outcomes Research Institute, Respiratory Health Association, Sickle Cell Disease Association of Illinois, Society of Hospital Medicine, The National Association of Social Workers Foundation, University of Illinois Sickle Cell Patient Council, University of Kentucky

Country where clinical trial is conducted

United States, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	PROMIS Emotional Distress-Anxiety (v1.0, SF4a)	Change in T-score from baseline to 30 days post discharge (30 days minus baseline).; A change in t-score <0 indicates improvement. A change equal to 0 indicates no change. A change >0 indicates worsening.	30 days post discharge
Primary	PROMIS Informational Support (v2.0, SF4a)	Change in T-score from baseline to 30 days post discharge (30 days minus baseline).; A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.	30 days post discharge
Secondary	PROMIS Emotional Support (v2.0, SF4a)	Change in T-score from baseline to 30 days post discharge (30 days minus baseline).; A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.	30 days post discharge
Secondary	PROMIS Instrumental Support (v2.0, SF4a)	Change in T-score from baseline to 30 days post discharge (30 days minus baseline).; A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.	30 days post discharge
Secondary	PROMIS Global Health, Physical (v1.1, SF)	Change in T-score from baseline to 30 days post discharge (30 days minus baseline).; A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.	30 days post discharge
Secondary	PROMIS Global Health, Mental (v1.1, SF)	Change in T-score from baseline to 30 days post discharge (30 days minus baseline).; A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.	30 days post discharge
Secondary	PROMIS Emotional Distress-Anxiety (v1.0, SF4a)	Change in T-score from baseline to 60 days post discharge (60 days minus baseline).; A change in t-score <0 indicates improvement. A change equal to 0 indicates no change. A change >0 indicates worsening.	60 days post discharge
Secondary	PROMIS Informational Support (v2.0, SF4a)	Change in T-score from baseline to 60 days post discharge (60 days minus baseline).; A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.	60 days post discharge
Secondary	PROMIS Emotional Support (v2.0, SF4a)	Change in T-score from baseline to 60 days post discharge (60 days minus baseline).; A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.	60 days post discharge
Secondary	PROMIS Instrumental Support (v2.0, SF4a)	Change in T-score from baseline to 60 days post discharge (60 days minus baseline).; A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.	60 days post discharge
Secondary	PROMIS Global Health, Physical (v1.1, SF)	Change in T-score from baseline to 60 days post discharge (60 days minus baseline).; A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.	60 days post discharge
Secondary	PROMIS Global Health, Mental (v1.1, SF)	Change in T-score from baseline to 60 days post discharge (60 days minus baseline).; A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.	60 days post discharge
Secondary	Death	Caregiver-reported and confirmed by EHR review	30 days post discharge
Secondary	Death	Caregiver-reported and confirmed by EHR review	60 days post discharge
Secondary	Re-hospitalization or Death	Confirmed by EHR review	30 days post discharge
Secondary	Re-hospitalization or Death	Confirmed by EHR review	60 days post discharge
Secondary	ED Visit, Re-hospitalization, or Death	Confirmed by EHR review	30 days post discharge
Secondary	ED Visit, Re-hospitalization, or Death	Confirmed by EHR review	60 days post discharge
Secondary	Outpatient Healthcare Visit	Self-reported	14 days post discharge
Secondary	Outpatient Healthcare Visit	EHR-reported	14 days post discharge

External Links

•   Patient-Centered Outcomes Research Institute (PCORI): Funding Award details