Effectiveness of Transitional Care Services

Post-cardiac Surgery Clinical Trial

Official title:

Can Refinements to Effective Transitional Care Services Improve Outcomes? Results From a Pragmatic, Randomized Controlled Trial.

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT03353155
• Other study ID #: NUHSCareHub
• Status: Completed
• Phase: N/A
• Start date: July 1, 2016
• Est. completion date: October 1, 2017

Study information

• Verified date: August 2018
• Source: Johns Hopkins University
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The National University Hospital System has designed and is piloting an improved post-discharge care programme called CareHub for patients undergoing cardiac surgery. CareHub is a post-discharge care programme that is designed to streamline and better coordinate current programmes for patients at high risk of readmission.

To assess the clinical and cost-effectiveness of CareHub, our team will randomly assign patients to a usual care setting or CareHub setting, and measure clinical outcomes, patient satisfaction, readmissions, and length of stay through 6 months post-discharge in both groups.Patients enrolled in both groups will receive post-discharge care for six months after discharge. CareHub patients will receive a single point of contact for access to usual care services. Recruitment for this pilot will be from 20 April 2016 - approximately late October 2016, and the CareHub team will provide 6 months of post-discharge support. The entire pilot will thus run from 20 April 2016 - April / May 2017, with data collection extending 6 months after the last patient is enrolled.

Description:

Today, the National University Hospital System has a variety of transitional / post-discharge care programmes, and patients may be enrolled in more than one. Each of these programmes is run by a different hospital team, so a patient may have to liaise with many parties for their post-discharge care.

The National University Hospital System has designed and is piloting an improved post-discharge care programme called CareHub for patients undergoing cardiac surgery. Recruitment for this pilot will be from 20 April 2016 - approximately late October 2016, and the CareHub team will provide 6 months of post-discharge support. The entire pilot will thus run from 20 April 2016 - April / May 2017.

CareHub is a post-discharge care programme that is designed to streamline and better coordinate current programmes for patients at high risk of readmission. Patients enrolled in CareHub and usual care will receive post-discharge care for six months after discharge. However, patients in CareHub will experience:

(i) Provision of a single point of contact for all the patient's needs, to help patients and their families navigate the healthcare system as well as various programmes available in the hospital and community. Care Coordinator identifies patients and starts working with care team during the inpatient phase, and follows patient through to the post-discharge phase.

(ii) More structured and regular telephone support and checks, to help ease the hospital-to-home transition, as well as to provide more opportunity to verify that patients are adhering to their recommended treatment (which may include e.g. checking that patients have made use of the daycare services CareHub recommended).

(iii) A call center which will operate during office hours, where tele-consult will be available from and nurses/care coordinators.

(iv) A consolidated multi-disciplinary discharge plan, based on the input of all healthcare workers caring for the patient. These include the CareHub coordinator, ward doctor and nurse, heart failure care manager, and allied health professionals, as required.

(v) Early identification and preparation for post-discharge care. Healthcare workers listed in (iv) will participate in a daily in-patient multi-disciplinary ward huddle, to discuss the patient's condition and start early preparation for post-discharge care.

To assess the clinical and cost-effectiveness of CareHub, our team will randomly assign patients to a usual care setting or CareHub setting, and measure clinical outcomes, patient satisfaction, readmissions, and length of stay through 6 months post-discharge in both groups.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 270
• Est. completion date: October 1, 2017
• Est. primary completion date: November 30, 2016
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years to 99 Years

Eligibility

Inclusion Criteria:

• All patients admitted to the cardiac inpatient service post-cardiac surgery

Exclusion Criteria:

• Patients that do not consent or are unable to consent to be included into CareHub

Related Conditions & MeSH terms

• Post-cardiac Surgery

Intervention

Behavioral:
• Usual Care

• CareHub

Locations

Country	Name	City	State
Singapore	National University Hospital	Singapore

Sponsors (2)

Lead Sponsor	Collaborator
Johns Hopkins University	National University Health System, Singapore

Country where clinical trial is conducted

Singapore, 

References & Publications (7)

Allen J, Hutchinson AM, Brown R, Livingston PM. Quality care outcomes following transitional care interventions for older people from hospital to home: a systematic review. BMC Health Serv Res. 2014 Aug 15;14:346. doi: 10.1186/1472-6963-14-346. Review. — View Citation

Coleman EA, Smith JD, Frank JC, Min SJ, Parry C, Kramer AM. Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention. J Am Geriatr Soc. 2004 Nov;52(11):1817-25. — View Citation

Coleman EA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc. 2003 Apr;51(4):549-55. Review. — View Citation

Greysen SR, Harrison JD, Kripalani S, Vasilevskis E, Robinson E, Metlay J, Schnipper JL, Meltzer D, Sehgal N, Ruhnke GW, Williams MV, Auerbach AD. Understanding patient-centred readmission factors: a multi-site, mixed-methods study. BMJ Qual Saf. 2017 Jan;26(1):33-41. doi: 10.1136/bmjqs-2015-004570. Epub 2016 Jan 14. — View Citation

Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009 Apr 2;360(14):1418-28. doi: 10.1056/NEJMsa0803563. Erratum in: N Engl J Med. 2011 Apr 21;364(16):1582. — View Citation

Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauly M. Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Ann Intern Med. 1994 Jun 15;120(12):999-1006. — View Citation

Wee SL, Loke CK, Liang C, Ganesan G, Wong LM, Cheah J. Effectiveness of a national transitional care program in reducing acute care use. J Am Geriatr Soc. 2014 Apr;62(4):747-53. doi: 10.1111/jgs.12750. Epub 2014 Mar 17. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Post-discharge length of stay	Patient's length of stay for any readmissions following index admission	6 months
Primary	Unplanned readmissions	Whether patients were admitted for a cardiac complaint after index admission	6 months
Primary	Cardiac-related specialist outpatient clinic visits	The number of post-index admission visits to an outpatient clinic for cardiac consults	6 months
Primary	Emergency department visits	The number of emergency department visits post-index admission	6 months
Secondary	Net cost of service utilization	CareHub cost/patient minus Usual Care cost/patient	6 months