Hospitalization Clinical Trial
Official title:
Intervening With and Improving Care for Patients at Risk for Frequent Hospital Admissions
Patients with frequent hospital admissions account for a disproportionate share of visits
and costs. An intervention that can bridge the gap between hospital and community based care
for a population of patients with frequent hospital admissions may offer both improved care
and cost savings if hospital admissions can be appropriately reduced. We are now using data
from our previous research to inform the development and implementation of an intervention
at Bellevue Hospital, which will bridge the gap between hospital and community based care
for a population of patients with frequent hospital admissions.
We hypothesize that such an intervention can offer both improved care and cost savings if
hospital admissions can be appropriately reduced.
In this protocol we outline a strategy to pilot a small-scale intervention on a small subset
of patients admitted to an urban public tertiary care safety net hospital who are defined by
our study criteria as at high risk for future readmission. By piloting components of the
intervention, we aim to assure the intervention functions as planned, and can deliver the
needed services to high risk patients in a seamless and patient-centered manner. The purpose
of this "feasibility study" is to ensure that when our intervention is implemented on a
larger scale, it appropriately serves enrolled patients needs, and that we are able to
effectively follow patients during the intervention period.
Status | Completed |
Enrollment | 19 |
Est. completion date | March 2009 |
Est. primary completion date | March 2009 |
Accepts healthy volunteers | No |
Gender | Both |
Age group | 18 Years to 64 Years |
Eligibility |
Inclusion Criteria: - Patients identified at the time of a current hospital admission by a predictive algorithm (algorithmic risk score of 50 or greater) as being at high risk for hospital readmission in the following 12 months - English or Spanish speaking - Fee-for-service Medicaid or uninsured patients - Ages 18-64 Exclusion Criteria: - Neither English or Spanish-speaking, - Institutionalized when not admitted to the hospital - Unable to communicate - HIV positive (because HIV positive patients have resources available to them from different and unrelated funding streams, and receive primary care at an off-site location) |
Endpoint Classification: Efficacy Study, Intervention Model: Single Group Assignment, Masking: Open Label, Primary Purpose: Health Services Research
Country | Name | City | State |
---|---|---|---|
United States | Bellevue Hospital Center Department of Emergency Medicine, A345 | New York | New York |
Lead Sponsor | Collaborator |
---|---|
New York University School of Medicine | The New York Community Trust, United Hospital Fund |
United States,
Type | Measure | Description | Time frame | Safety issue |
---|---|---|---|---|
Primary | Housing placement | Number of eligible chronically homeless patients placed in transitional or permanent housing | 1 year | No |
Secondary | Patient retention in program | Number of subjects lost to follow-up and who did not engage after program enrollment | 1 year | No |
Secondary | Linkage to primary care provider | Number of patients without a primary care provider who were successfully linked to primary care (at least two visits) | 1 year | No |
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