Patient Readmission Clinical Trial
Official title:
Evaluation of a Novel Hospital Discharge Clinic to Improve Care Coordination and Reduce Rehospitalization Among Low Income Adults
Verified date | June 2019 |
Source | Northwestern University |
Contact | n/a |
Is FDA regulated | No |
Health authority | |
Study type | Interventional |
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.
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 |
Country | Name | City | State |
---|---|---|---|
United States | Northwestern Memorial Hospital | Chicago | Illinois |
Lead Sponsor | Collaborator |
---|---|
Northwestern University | Northwestern Memorial Hospital |
United States,
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
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 |
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