Patient Discharge Clinical Trial
Official title:
Improving Hospital-to-Home Care Transitions for High-risk Younger Adult Patients at a Safety Net Hospital: Activating Partnerships Among Patients, Families and Medical Staff
Verified date | August 2016 |
Source | Cambridge Health Alliance |
Contact | n/a |
Is FDA regulated | No |
Health authority | United States: Institutional Review Board |
Study type | Interventional |
Improving hospital-to-home care transitions can produce improvements in patient safety and
health care outcomes, while decreasing medical costs. Most transitions research has examined
strategies for older patients. This project, however, focuses on younger, high-risk patients
within a safety net system. The proposed intervention is based on research that patient
activation, as measured by the Patient Activation Measure (PAM), is correlated with risk for
hospital readmission. The intervention seeks to increase PAM scores by employing a
Transition Coach to coach patients, prior to and for 30-days after discharge, to (1) improve
self-management skills through goal setting and goal attainment; (2) to enhance patient
capacity to engage in trusting relationships with the Primary Care Provider (PCP), other
medical specialists, family members of friends, and the Transition Coach; and (3) to improve
ability to navigate the medical system.
The investigators will conduct a randomized trial to determine; (a) if PAM scores can be
increased in the 30-day after hospital discharge; (b) if increased PAM scores, in this
setting, are correlated with changes in healthcare utilization patterns; and (c) if the
intervention presents a viable strategy to change healthcare utilization patterns and reduce
rehospitalizations.
Status | Completed |
Enrollment | 201 |
Est. completion date | July 2016 |
Est. primary completion date | July 2016 |
Accepts healthy volunteers | Accepts Healthy Volunteers |
Gender | Both |
Age group | 18 Years to 60 Years |
Eligibility |
Inclusion Criteria: - Age 60 or less - PCP within CHA network - Have had at least one previous hospitalization or two or more Emergency Department visit within CHA in the past year - Hospitalized at Cambridge Hospital on Medicine or Surgery Service - Discharged from Medicine or Surgery service to home Exclusion Criteria: - Age > 60; - Non-CHA PCP - Discharged to rehabilitation or transferred to an outside hospital or to Psychiatry service |
Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Single Blind (Outcomes Assessor), Primary Purpose: Health Services Research
Country | Name | City | State |
---|---|---|---|
United States | Cambridge Hospital | Cambridge | Massachusetts |
Lead Sponsor | Collaborator |
---|---|
Cambridge Health Alliance |
United States,
Type | Measure | Description | Time frame | Safety issue |
---|---|---|---|---|
Other | Pre-intervention utilization | ED visits, hospital admissions, outpatient visits, outpatient no-shows | 1 year pre-hospitalization | No |
Primary | Change from Baseline - Patient Activation Measure (PAM) and Utilization | Comparison between pre-discharge PAM and 30-day post-discharge PAM. Hospital and ED visit and outpatient visits with PCP and Specialists at 7,14,30,60,90 days. | 7,14, 30, 60, 90 days post-discharge | No |
Secondary | Goal Setting and Achievement | Number of goals defined and number of goals achieved | Hospital visit and 30 days post-discharge | No |
Secondary | Relationship with Transition Coach (TC) | Number of encounters with TC (Hospital visits, Face-to-face visits, telephone outreach) and was TC acknowledged to be helpful in post-discharge period. | Hospital visit and 30 days post-discharge | No |
Secondary | Relationship with PCP | Number of PCP visits and was PCP acknowledged to be helpful in post-discharge period. | 30 days post-discharge | No |
Secondary | Relationship with other medical providers | Number of specialty (non-psych) visit. Number of Psychiatric visits. | 30 days post-discharge | No |
Secondary | Relationship with Home Support | Were friends or family acknowledged to be helpful in post-discharge period? | 30 days post-discharge | No |
Secondary | Ability to navigate health care system | Number of no-shows | 30, 60,180 days post-discharge | No |
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