Care Transitions Innovation (C-TraIn)

Hospitalization Clinical Trial

Official title:

Care Transitions Innovation (C-TraIn): Study of a Multi-component Transitional Care Intervention for Uninsured and Low-income Publicly Insured Adults

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT01906645
• Other study ID #: OHSU eIRB 6208
• Status: Completed
• Phase: N/A
• First received: July 17, 2013
• Last updated: July 19, 2013
• Start date: November 2010

Study information

• Verified date: July 2013
• Source: Oregon Health and Science University
• Contact: n/a
• Is FDA regulated: No
• Health authority: United States: Institutional Review Board
• Study type: Interventional

Clinical Trial Summary

The purpose of this protocol is to evaluate the Care Transitons Innovation, a quality improvement project being implemented at OHSU to improve the transition from hospital to home for uninsured and Medicaid patients admitted to general medicine and cardiology wards at OHSU. The evaluation includes a baseline in-person survey and a 30 day post-discharge phone follow-up survey. Prior to C-TraIn, the local healthcare delivery model lacked an effective way to assure timely, safe, and effective follow-up care for uninsured and underinsured hospitalized patients. Most uninsured patients have no source for primary care, and many have limited social support, complex medical problems, and are prescribed many medications. Patients are frequently discharged without any coordinated plan for follow up. Based on a needs assessment performed in 2009 (OHSU eIRB 5514) investigators developed a quality improvement program that will include three major components: 1) a care transitions RN advocate who will see patients in the hospital and after discharge, 2) a pharmacy consultation and 30 days of medications post-discharge, 3) linkages with primary care medical homes, including payment for primary care for uninsured patients who lack a usual source of care, and 4) monthly meetings that serve as a platform for continuous quality improvement. In order to measure the success of our program, investigators will track patient utilization, sociodemographic factors, and patient factors including satisfaction, activation, and self-reported health status. To be included patients must be uninsured, have Oregon Medicaid, or be low income (200% or less of federal poverty level) Medicare recipients, and live within Multnomah, Washington and Clackamas Counties in Oregon.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 382
• Est. primary completion date: March 2012
• Accepts healthy volunteers: No
• Gender: Both
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

• hospitalized on one of seven inpatient treatment teams

• uninsured or low-income publicly insured (Medicaid; Medicare/Medicaid; or Medicare without supplemental insurance and =200% poverty level)

• reside in one of three metro-area counties (Multnomah, Washington, Clackamas)

Exclusion Criteria:

• not community dwelling (ie not from a long-term care facility or with plans to discharge to skilled nursing facility)

• no access to a working telephone (participants could list a friend or shelter phone)

• non-English speakding

• HIV positive (HIV+ patients were eligible for overlapping transitional care resources)

• disabling mental illness (as characterized by active psychosis or active suicidal ideation) or severe cognitive deficits

• plans to enter hospice.

Study Design

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

Related Conditions & MeSH terms

• Hospitalization

Intervention

Other:
• Care Transitions Innovation (C-TraIn)
Multi-component transitional care intervention including transitional nursing care, pharmacy care, and medical home linkages

Locations

Country	Name	City	State
United States	Oregon Health & Science University	Portland	Oregon

Sponsors (1)

Lead Sponsor	Collaborator
Oregon Health and Science University

Country where clinical trial is conducted

United States, 

References & Publications (1)

Englander H, Kansagara D. Planning and designing the care transitions innovation (C-Train) for uninsured and Medicaid patients. J Hosp Med. 2012 Sep;7(7):524-9. doi: 10.1002/jhm.1926. Epub 2012 Mar 12. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Other	Patient Activation Measure	Patient Activation Measure (PAM) is a 13-item validated measure of patient activation developed by Judith Hibbard and colleagues.; Hibbard JH, Stockard J, Mahoney ER, Tusler M. Development of the patient activation measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Serv Res. 2004;39 (4 pt 1):1005-1026.	30-days post-discharge	No
Primary	30-day hospital readmissions		30-days	No
Primary	Emergency Department use		30-days post-discharge	No
Secondary	Care Transitions Measure (CTM-3)	The 3 item care transitions measure (CTM-3) is a validated measure that assesses the quality of the care transition. It asks patients to rate agreement with the following: The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital.; When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.; When I left the hospital, I clearly understood the purpose for taking each of my medications.; It is being considered by NQF for public reporting. More Background can be found at: http://www.caretransitions.org/documents/CTM_FAQs.pdf	Patient report at 30-days post hospital discharge	No
Secondary	all cause mortality		30-days post-discharge	No