Effectiveness of Nurse-based Care Coordination on Readmissions Among Primary Care Patients: a Stepped Wedge Cluster Randomized Trial

Patient Activation Clinical Trial

Official title:

Effectiveness of Nurse-based Care Coordination on Readmissions Among Primary Care Patients: a Stepped Wedge Cluster Randomized Trial

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT04224220
• Other study ID #: 19-009784
• Status: Completed
• Phase: N/A
• Start date: January 1, 2020
• Est. completion date: January 1, 2023

Study information

• Verified date: February 2023
• Source: Mayo Clinic
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

This trial will evaluate the effectiveness of nurse-based care coordination and nurse-based remote patient monitoring on hospital readmissions among primary care patients.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 1947
• Est. completion date: January 1, 2023
• Est. primary completion date: July 1, 2022
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

• Discharged from the hospital in the past 7 days

• LACE+ score of 59 or greater and at least two chronic conditions

• Index hospitalization with discharge directly to community dwelling home (home, assisted living)

• English speaking

• Normal cognitive function - mild dementia or mild cognitive impairment is allowed if a caregiver is able to work with the care coordinator and patient during program enrollment

• Mayo Clinic or Mayo Clinic Health System provider managing the patient's care (e.g. primary care); patient is assigned to the panel of a Mayo Clinic Medical Doctor/Nurse Practitioner/Physician Assistant

• Access to and ability to communicate via telephone (either patient or caregiver)

Exclusion Criteria:

• Psychiatric hospital admission

• Patients with a serious and persistent mental health disorder or severe treatment interfering behavior that require a higher level of service than is available at the patient's clinic

• Untreated active substance or alcohol abuse

• Dementia or moderate to severe cognitive impairment

• Discharged to one of the following: rehabilitation unit, skilled nursing facility, assisted living memory unit, group home

• Pregnancy

• Active treatment for cancer

• Receiving dialysis or transplant services

• Life expectancy < 6 months or enrolled in hospice or palliative care programs

• Patient is unwilling to sign a Release of Information (ROI); ROI allows those providing care, internal and external, to be actively involved in the patient's care coordination

• Patients with active tuberculosis (TB)

• Violent patient flag noted in Epic (for adult medical care coordination)

• Patient declines home visit (for adult medical care coordination)

• Patient is already enrolled in remote patient monitoring or the care transitions program

Related Conditions & MeSH terms

• Patient Activation

Intervention

Other:
• Adult Medical Care Coordination
Nurse-based support that includes a home visit and follow-up coaching telephone calls to monitor patient status and ability to self-manage symptoms.
• Remote Patient Monitoring
Nurse-based support and coaching that incorporates the use of technology to monitor patient status and ability to self-manage symptoms.

Locations

Country	Name	City	State
United States	Mayo Clinic	Rochester	Minnesota

Sponsors (1)

Lead Sponsor	Collaborator
Mayo Clinic

Country where clinical trial is conducted

United States, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Rate of Readmission	The rate of patients revisiting the emergency department or being admitted to the hospital	30 days

External Links

•   Mayo Clinic Clinical Trials