Clinical Trials Logo

Clinical Trial Summary

The Enhanced Discharge Planning Program (EDPP) is an intervention designed to help older adults safely transition to the community after discharge. This is achieved through telephonic care coordination facilitated by social workers. EDPP social workers ensure full implementation of the discharge plan, assist with coordinating community resources and follow-up appointments, and intervene around other issues that may arise as a result of a complex transition. The EDPP intervention is currently being offered to some older adult patients discharged from Rush University Medical Center. Case managers refer older adult patients on selected units who they believe may be at risk for adverse events post-discharge. While this service is being provided to patients, it has not yet been formally evaluated. This randomized controlled trial will provide data necessary for a more rigorous evaluation of the efficacy of this intervention.


Clinical Trial Description

The Enhanced Discharge Planning Program (EDPP) is an intervention designed to help older adults safely transition to the community after discharge. This is achieved through telephonic care coordination facilitated by social workers. EDPP social workers ensure full implementation of the discharge plan, assist with coordinating community resources and follow-up appointments, and intervene around other issues that may arise as a result of a complex transition. The EDPP intervention is currently being offered to some older adult patients discharged from Rush University Medical Center. Case managers refer older adult patients on selected units who they believe may be at risk for adverse events post-discharge. While this service is being provided to patients, it has not yet been formally evaluated. This randomized controlled trial will provide data necessary for a more rigorous evaluation of the efficacy of this intervention. Research Process 1. Rush University Medical Center inpatients receive the Enhanced Discharge Planning Program information sheet in the Rush patient education packet. All Rush inpatients will receive an informational sheet about the EDPP study, with an exception of pediatric and labor/delivery inpatients. The sheet will be included in the patient education packets distributed by Rush. This will make patients aware of the EDPP program before they leave the hospital and prepare them for a call once they return home. 2. Eligible patients are referred to the Enhanced Discharge Planning Program at their point of discharge via an electronic referral report through Epic. EDPP receives an electronic referral report of all patients meeting the specified referral criteria. Referral is dependent on discharge data recorded by Rush nurses and case managers in the Epic electronic medical record and generated at the point of discharge. The electronic system ensures a streamlined, standardized referral process by creating an automatic referral based upon documentation completed as part of nurse's and case manager's typical workflow. An anticipated 720 patients will be electronically referred during the duration of the study. 3. The Enhanced Discharge Planning Program project coordinator receives the daily referral report and inputs patients into the block randomization scheme. The project coordinator will input referrals into the existing block randomization scheme after receiving the electronic report at the beginning of the day. Referrals will be copied into the scheme in the same order as reported - sorted by episode number - to reduce bias. Patients assigned to the intervention group will be forwarded to the EDPP social workers. The usual care group will be managed by the project coordinator and student interns under her direct supervision. 4. The Enhanced Discharge Planning Program social worker contacts the intervention group to provide clinical care and obtain consent. ;


Study Design


Related Conditions & MeSH terms


NCT number NCT01378234
Study type Interventional
Source Rush University Medical Center
Contact
Status Completed
Phase N/A
Start date June 2009
Completion date July 2010

See also
  Status Clinical Trial Phase
Completed NCT01207180 - Discharge Planning for Elderly Patients in the Emergency Department: Use of a Brief Phone Call After Discharge to Improve Medication Utilization and Physician Follow-up N/A
Not yet recruiting NCT05501314 - Remote Home Monitoring Acute Pancreatitis N/A
Completed NCT03223584 - Exploratory Study to Inventory Opportunities to Optimize Continuity of Pharmacotherapy at Hospital Discharge N/A
Completed NCT02581800 - Effect and Experience of PreHomeCare of Preterm Infants Using Telecommunication and Smartphone Application N/A
Completed NCT02295319 - The Impact of Individual-based Discharges From Acute Admission Units to Home N/A
Completed NCT00670865 - Automated Versus Conventional Hospital Discharge Summaries and Prescriptions N/A
Completed NCT05556707 - Symptom Clusters and Risk Factors of COVID-19 Patients
Terminated NCT03455985 - Effectiveness of a Diabetes Focused Discharge Order Set Among Poorly Controlled Hospitalized Patients Transitioning to Glargine U300 Insulin N/A
Completed NCT01091688 - The Impact of Just-in-time Information on Neonatal Intensive Care Unit (NICU) Discharges N/A
Completed NCT03810534 - Connect-Home Clinical Trial N/A
Completed NCT02532296 - Improving Hospital-to-Home Care Transitions for High-risk Younger Adult Patients N/A
Recruiting NCT04077281 - Improving Medication Prescribing-Related Outcomes for Vulnerable Elderly In Transitions N/A
Completed NCT03436940 - Comparison Between Two Strategies of Discharge Planning for the Reduction of Short Term Hospital Readmissions N/A
Completed NCT01565785 - Evaluating a New Way to Prepare Parents of Hospitalized Children for Discharge and Management of Child at Home N/A
Recruiting NCT03786250 - Comprehensive Geriatric Assessment in an Emergency Department
Completed NCT02533856 - Trial of Emergency Department Discharge With Enhanced Transitions of Care Compared to Usual Care N/A
Withdrawn NCT00364117 - Remote Presence Timely Discharge Management Phase 2/Phase 3
Completed NCT01503554 - Combined Social Worker and Pharmacist Transitional Care Program N/A
Not yet recruiting NCT04351425 - Early Weaning of Preterm Newborn From Incubator to Cot at 1400 Grams N/A