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Clinical Trial Details — Status: Completed

Administrative data

NCT number NCT01378234
Other study ID # 08121903-IRB02
Secondary ID
Status Completed
Phase N/A
First received
Last updated
Start date June 2009
Est. completion date July 2010

Study information

Verified date September 2023
Source Rush University Medical Center
Contact n/a
Is FDA regulated No
Health authority
Study type Interventional

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.


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.


Recruitment information / eligibility

Status Completed
Enrollment 740
Est. completion date July 2010
Est. primary completion date July 2010
Accepts healthy volunteers No
Gender All
Age group 65 Years and older
Eligibility Inclusion Criteria: - Must meet all the following criteria: - Aged 65+ - English speaking - Returning home after discharge - 7+ medication prescribed - Must also meet one additional criterion: - Lives alone - Without a source of emotional support - Without a support system for care in place - Discharged with a service referral - High risk for falls - Inpatient hospitalization within 12 months - Identified in depth psychosocial need - High risk medication prescribed Exclusion Criteria: - Primary diagnosis of transplant - Non-English speaking - Discharged to a facility

Study Design


Related Conditions & MeSH terms


Intervention

Behavioral:
Enhanced Discharge Planning Program transitional care
Enhanced Discharge Planning Program (EDPP) provides telephonic short-term post-discharge social work services that assess and intervene from a biopsychosocial perspective for at-risk older adults returning home after an inpatient hospitalization. EDPP follows a four-step process to with three guiding tasks to reach the goal of preventing avoidable adverse events post-discharge: Ensure patients understand the discharge plan of care and receive recommended services while screening for unidentified medical or social needs Connect patients to outpatient health services (ex: home health, in-home services, dialysis, radiology, laboratory services, specialty care) with particular emphasis on the first physician follow-up appointment Supporting caregivers to reduce stress and burden

Locations

Country Name City State
United States Rush University Medical Center Chicago Illinois

Sponsors (1)

Lead Sponsor Collaborator
Rush University Medical Center

Country where clinical trial is conducted

United States, 

Outcome

Type Measure Description Time frame Safety issue
Primary Readmissions Readmission to hospital within 30 days after index discharge date 30 days
Primary Readmissions Readmission to hospital within 60 days of index discharge date 60 days
Primary Readmissions Readmission to hospital within 90 days of index discharge date 90 days
Primary Readmissions Readmission to hospital within 180 days of index discharge date 180 days
Secondary Stress Patient and caregiver stress, self-reported 30 days
Secondary Physician follow-up Appointment made, kept with doctor 30 days
Secondary Mortality patient's Mortality will be monitored and documented. 30 days
Secondary Patient needs Audit of problems detected post-discharge 30 days
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