Post-discharge Clinical Trial
Official title:
Trial of the CarePartner Program for Improving the Quality of Transition Support
Background: Patients hospitalized with complex chronic conditions frequently experience
preventable short-term readmissions due to inadequate transition support. Although
structured discharge planning with telephone follow-up improves transition outcomes, these
services often are unavailable, and proactive outreach is often inadequate once the patient
returns home. Informal caregivers are invaluable for ensuring successful transitions, but
many patients live alone, have an in-home caregiver who is struggling with competing
demands, or live at a distance from adult children or other potential sources of support.
New models are needed for transition support that include low-cost technologies and more
structured assistance for patients' informal caregiving network, while providing patients'
clinical teams with the information they need to avert health crises.
Objectives: Consistent with Agency for Healthcare Research and Quality goals to improve
transitions using accessible health IT, we will evaluate a novel intervention designed to
improve the effectiveness of transition support for common chronic conditions via three
mechanisms of action: (a) direct tailored communication to patients via automated calls post
discharge, (b) support for informal caregivers via structured feedback about the patient's
status and advice about how they can help, and (c) support for proactive care management
including a web-based disease management tool, automated alerts about potential problems,
and the capacity for asynchronous communication with patients and their caregivers.
Specifically, the trial will determine: 1) whether the CarePartner intervention improves
patients' readmission risk and functional status; 2) the impact of the intervention on
patients' self-care behaviors and the quality of the transition process; and 3) whether the
intervention improves caregiver burden and stress levels.
Methods: 422 adults with complex chronic conditions will be identified upon admission to a university-based acute care general medical service. Patients will be asked to identify a CarePartner (CP) living outside their household; CPs will be spouses, adult children, and others in their social network willing to play an active role in their transition support. Patients will be randomized to the intervention or usual care. Intervention patients will receive automated assessment and behavior change calls, and their CPs will receive structured feedback and advice following each assessment. Patients' clinical team will have access to patients' assessment results via the web, will receive automated reports about urgent health problems, and will be able to communicate asynchronously with patients and CPs using a secure web page and a specially designed voicemail service. Patients will complete surveys at baseline, 30- and 90- days post discharge; utilization data will be obtained from hospital records. CPs and clinicians will be interviewed to evaluate intervention effects on processes of self-care support, caregiver stress and communication, and the intervention's potential for broader implementation. The primary outcome will be 30 day readmission rates; 2ndary outcomes include functional status, self-care behaviors, and mortality risk. ;
Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Health Services Research
| Status | Clinical Trial | Phase | |
|---|---|---|---|
| Recruiting |
NCT05430789 -
Post-discharge Cessation for Smoking Patients
|
N/A | |
| Completed |
NCT01672385 -
Improving Transition Outcomes Through Accessible Health IT and Caregiver Support
|
N/A |