Evaluation of a Hospital Discharge Clinic to Improve Care Coordination and Reduce Rehospitalization in Low Income Adults

Patient Readmission Clinical Trial

Official title:

Evaluation of a Novel Hospital Discharge Clinic to Improve Care Coordination and Reduce Rehospitalization Among Low Income Adults

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT03066492
• Other study ID #: STU00200259
• Status: Completed
• Phase: N/A
• Start date: September 2, 2015
• Est. completion date: May 1, 2017

Study information

• Verified date: June 2019
• Source: Northwestern University
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

This randomized controlled trial examines the effects of a transitional care clinic for high-risk patients at an academic medical center who had no trusted medical home. The trial will provide the first reliable evaluation of the Northwestern Transitional Care Clinic / Follow Up Clinic's (NFC) impact on re-admissions, care coordination, and costs. This research will allow us to assess the value of the NFC and similar models of care for providing a more coordinated care approach that results in better treatment outcomes for urban poor populations.

It is hypothesized that NFC patients will have fewer 90-day re-hospitalizations and are more likely to have a usual source of primary care 6 months after discharge.

Description:

The Northwestern Transitional Care Follow-up Clinic (NFC) was established in 2012 to improve the coordination of care for these patients following inpatient or Emergency Department discharge from Northwestern Memorial Hospital. Since 2012, the NFC has constructed an integrated team care approach, logging about 2000 post-discharge encounters with Medicaid or patients without insurance. The NFC model has evolved over the past 2 years in response to a need to address mental as well as physical health needs and to interface with community resources to address social determinants of health that might otherwise lead to frequent re-admission. By working with clinical partners and public payers like Medicaid and County Care, the NFC has also worked to transition patients to accessible primary care medical homes that will provide behavioral, physical, and preventive care. The current study will provide the first reliable evaluation of the clinic's impact on re-admissions, care coordination, and costs. This research will allow us to assess the value of the NFC and similar models of care for providing a more coordinated care approach that results in better treatment outcomes for urban poor populations.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 654
• Est. completion date: May 1, 2017
• Est. primary completion date: May 1, 2016
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

• All patients eligible for Northwestern Transitional Follow Up care post-discharge from Northwestern Memorial Hospital

• Adults (18 years of age or older)

• Patients referred by an Northwestern Memorial Hospital care provider for discharge coordination by the Northwestern Transitional Follow Up Clinic

Exclusion Criteria:

• Individuals who are not yet adults (infants, children, teenagers)

• Pregnant Women

• Prisoners

Related Conditions & MeSH terms

• Patient Readmission

Intervention

Other:
• Northwestern Follow Up Care Coordination
Each patient is provided with information by telephone and mail, offering assistance to receive a follow-up appointment at the Northwestern Transitional Care Follow Up Clinic.
• Federally Qualified Health Center
Each patient is provided with information by telephone and mail, offering assistance to receive a follow-up appointment at a nearby Federally Qualified Health Center.

Locations

Country	Name	City	State
United States	Northwestern Memorial Hospital	Chicago	Illinois

Sponsors (2)

Lead Sponsor	Collaborator
Northwestern University	Northwestern Memorial Hospital

Country where clinical trial is conducted

United States, 

References & Publications (1)

Liss DT, Ackermann RT, Cooper A, Finch EA, Hurt C, Lancki N, Rogers A, Sheth A, Teter C, Schaeffer C. Effects of a Transitional Care Practice for a Vulnerable Population: a Pragmatic, Randomized Comparative Effectiveness Trial. J Gen Intern Med. 2019 May — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	90-Day Re-hospitalization or Death	90-day re-hospitalization (Emergency Department and/or inpatient admission) or death	90 days
Secondary	Usual Source of Primary Care	Patient report of being seen in a usual source of primary medical care 6 months after discharge	6 months
Secondary	30-Day Re-hospitalization or Death	90-day re-hospitalization (Emergency Department and/or inpatient admission) or death	30 days
Secondary	180-Day Re-hospitalization or Death	180-day re-hospitalization (Emergency Department and/or inpatient admission) or death	180 days
Secondary	365-Day Re-hospitalization or Death	365-day re-hospitalization (Emergency Department and/or inpatient admission) or death	365 days
Secondary	Health Advocate Effect	This evaluation will determine if being offered support of a novel care team member known as a "health advocate" (a form of care navigator who will assist patients to overcome social determinants of readmission) is more likely to prevent hospital readmission than receiving the standard Northwestern Transitional Follow Up Care team intervention alone.	12 months
Secondary	Intervention Cost	This is an evaluation of the incremental costs to implement and sustain standard Northwestern Transitional Follow Up team care, as well as the enhanced standard + health advocate personnel model	12 months