Patient Activation Clinical Trial
Official title:
Effectiveness of Nurse-based Care Coordination on Readmissions Among Primary Care Patients: a Stepped Wedge Cluster Randomized Trial
Verified date | February 2023 |
Source | Mayo Clinic |
Contact | n/a |
Is FDA regulated | No |
Health authority | |
Study type | Interventional |
This trial will evaluate the effectiveness of nurse-based care coordination and nurse-based remote patient monitoring on hospital readmissions among primary care patients.
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 |
Country | Name | City | State |
---|---|---|---|
United States | Mayo Clinic | Rochester | Minnesota |
Lead Sponsor | Collaborator |
---|---|
Mayo Clinic |
United States,
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 |
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