Clinical Trials Logo

Clinical Trial Summary

Patients with frequent hospital admissions account for a disproportionate share of visits and costs. An intervention that can bridge the gap between hospital and community based care for a population of patients with frequent hospital admissions may offer both improved care and cost savings if hospital admissions can be appropriately reduced. We are now using data from our previous research to inform the development and implementation of an intervention at Bellevue Hospital, which will bridge the gap between hospital and community based care for a population of patients with frequent hospital admissions.

We hypothesize that such an intervention can offer both improved care and cost savings if hospital admissions can be appropriately reduced.

In this protocol we outline a strategy to pilot a small-scale intervention on a small subset of patients admitted to an urban public tertiary care safety net hospital who are defined by our study criteria as at high risk for future readmission. By piloting components of the intervention, we aim to assure the intervention functions as planned, and can deliver the needed services to high risk patients in a seamless and patient-centered manner. The purpose of this "feasibility study" is to ensure that when our intervention is implemented on a larger scale, it appropriately serves enrolled patients needs, and that we are able to effectively follow patients during the intervention period.


Clinical Trial Description

In pilot research, we found that high users at Bellevue Hospital Center had varied indications for admission to the hospital, but also shared many risk factors that have been traditionally difficult for the health care system to address, including homelessness, social isolation, substance use, depression and anxiety, and fragmented primary care. Coordination of the multiple service types required to improve care for such patients across hospitals, clinics, and community-based organizations is hindered by financial disincentives, restrictive funding streams, and poor communication among service providers Intervention model and team: The pilot intervention will begin at the patient's bedside in the hospital and continue after his/her discharge into the community, utilizing a flexible and intensive care management model with a multi-disciplinary team approach. Community Based Care Managers (CBCMs) overseen by a social worker, will connect patients to needed community services including housing for homeless patients, accompany patients to appointments and facilitate transportation to medical, benefits enrollment, and perform other services based in the hospital and community.

So that the intervention can address the multitude of complex medical and social needs of high risk patients, in addition to our community partners that address the needs of homeless patients, we will partner with additional community providers of mental health, substance use, and home medical services who will assist our intervention team staff in managing patients' care after hospital discharge. In addition, we will build upon existing specialized health and social services within Bellevue Hospital (e.g. provision of prompt outpatient clinic appointments) so that this population is better and more effectively served.

Specific Aims

1) evaluate the patient and provider experience with various potential components of a pilot intervention plan for high risk, high cost patients, (identified using a predictive case-finding algorithm) conducted in partnership with community providers of homeless, mental health, substance use, and other key services, and 2) evaluate the feasibility of several aspects of the intervention. By piloting and evaluating components of the intervention, we aim to assure the intervention functions as planned, and can deliver the needed services to high risk patients.

Outcomes:

Ability of intervention team to:

1. Function effectively (e.g. communicate and coordinate with one another and with other departments in the hospital)

2. Match patients to appropriate services

3. Obtain supportive housing for homeless patients with Common Ground partner

4. Maintain contact with patients after initial hospital discharge

5. Facilitate patient adherence to outpatient appointments

6. Link patients with no usual source of care to PMD ;


Study Design

Endpoint Classification: Efficacy Study, Intervention Model: Single Group Assignment, Masking: Open Label, Primary Purpose: Health Services Research


Related Conditions & MeSH terms


NCT number NCT01292096
Study type Interventional
Source New York University School of Medicine
Contact
Status Completed
Phase Phase 1
Start date August 2007
Completion date March 2009

See also
  Status Clinical Trial Phase
Completed NCT03297567 - Physical Therapy Guidelines For Hospitalized Elderly N/A
Terminated NCT03825497 - The WALK-Copenhagen Trial (WALK-Cph): a Mixed Methods Study N/A
Completed NCT06293768 - Continuous Wireless Monitoring for Patients in the Internal Medicine UOC. Randomized Controlled Trial (GreenLineH-T) N/A
Completed NCT03296423 - Bacillus Calmette-guérin Vaccination to Prevent Infections of the Elderly Phase 4
Not yet recruiting NCT05550272 - Hospitalizations in Neonatal Period and Early Discharge of Maternity
Completed NCT02614638 - Evaluation of the Impact of the Presence of a Pharmacy Technician on the Quality and Cost of Drug Therapy N/A
Completed NCT01931553 - A Pragmatic Cluster Randomized Controlled Trial to Standardize Attending Morning Rounds in Medicine N/A
Completed NCT00527774 - Effect of HCV Infection on Insulin Resistance and Malnutrition-inflammation Complex Syndrome in Regular Hemodialysis Patients N/A
Completed NCT02598115 - Impact of Collaborative Pharmaceutical Care on Hospital Admission Drug Prescriptions for Patients 65 Years of Age and Older N/A
Recruiting NCT05366075 - The Preventing Functional Decline in Acutely Hospitalized Older Patients (PREV_FUNC) Study Phase 3
Not yet recruiting NCT05522647 - Detection of Risk Behaviors: Pilot Observational Study With Bedridden and Agitated Patients.
Terminated NCT04257422 - Intentional Rounding in Internal Medicine N/A
Completed NCT00244673 - Randomized Study of Not Giving Diphteria-tetanus-pertussis Vaccination With or After Measles Vaccination Phase 4
Completed NCT00370916 - Reducing Transition Drug Risk N/A
Recruiting NCT04078334 - Personalized Exercises Program Prescription to Prevent Functional Decline Throughout Older Adults Hospitalization N/A
Active, not recruiting NCT04235374 - Implementation of Function Focused Care in Acute Care N/A
Recruiting NCT03651414 - Safety Issues and SurvIval For Medical Outliers
Completed NCT05247060 - Orthostatic Hypotension in Hypertensive Patient Hospitalized in Internal Medicine
Terminated NCT05518474 - Self-proning and Repositioning in COVID-19 Outpatients at Risk of Complicated Illness N/A
Recruiting NCT05036824 - Intensive Dose Tinzaparin in Hospitalized COVID-19 Patients