Care Transitions for Complex Patient - Cycle 1 and Cycle 2

NCT01039324 | Completed

• 2 other identifiers: Pro00010738R18HS017795
• Study Type: interventional
• Target: 8,422
• Locations: 1 country
• Sites: 1

Brief Summary

The purpose of this study is to improve patient care and safety while decreasing ED visit rates by sending specific information about care transitions related to hospital admission and discharge and emergency department and specialty care visits to primary care practices, care managers and patients with the use of health information technology (HIT) shared across a community-based network of providers. Cycle 1 focuses on the impact of notices about ED encounters and hospitalizations derived from billing data that are sent to care managers for all 47,000 patients in the Northern Piedmont Community Care Network (NPCCN). Cycle 2 explores the impact of letters sent to patients, and care event reports sent to a patient's medical home in addition to notices sent to care managers about ED encounters, hospitalization and specialty care based on ADT (Admission Discharge Transfer) and billing data on 4,600 patients with complex health needs.

Conditions

Asthma; Coronary Artery Disease; Diabetes; Hypertension; Congestive Heart Failure

Keywords

Complex patients; Care transitions; Patient safety; Patient care; Health Information Technology; Health Information Exchange; Clinical Decision Support; Care coordination; Data sharing

Outcome Measures

Primary Outcomes (1)

• Emergency department encounter rates among patients in the study population.

  6 months

Secondary Outcomes (22)

• Emergency department encounter rates for low severity diagnoses among all patients.

  6 months

• Total emergency department encounter rates among patients for whom intervention was appropriate.

  6 months

• Total emergency department encounter rates among all patients.

  6 months

• Hospitalization rates among patients for whom intervention was appropriate.

  6 months

• Hospitalization rates among all patients.

  6 months

Study Arms (3)

Intermediate Intervention (arm #1)

EXPERIMENTAL

Care transition reports sent to primary care clinics, care transition letters sent to patients, release of information requests about care transitions sent on behalf of primary care clinics.

Other: Reports

Full Intervention (arm #2)

EXPERIMENTAL

E-mail notices sent to care managers about care transitions plus care transition reports sent to primary care clinics, care transition reports sent to patients, release of information requests about care transitions sent on behalf of primary care clinics.

Other: Reports and Notices

Control (arm #3)

EXPERIMENTAL

Subjects assigned to the control group will receive "usual care" which is the standard of care coordination currently existent between patients, providers and care managers.

Other: Usual care

Interventions

Reports OTHER

Primary care event reports and patient letters

Intermediate Intervention (arm #1)

Reports and Notices OTHER

Primary care event reports, patient letters and care manager notices

Full Intervention (arm #2)

Usual care OTHER

This is the study's control group

Control (arm #3)

Eligibility Criteria

• Sex: all
• Healthy Volunteers: No
• Age Groups: Child (0-17), Adult (18-64), Older Adult (65+)

You may qualify if:

• North Carolina Medicaid beneficiary enrolled in the Northern Piedmont Community Care Network (NPCCN)
• Has complex healthcare needs as defined by having two or more IOM (Institute of Medicine) priority conditions (hypertension, coronary artery disease, congestive heart failure, stroke, asthma, diabetes) OR one of the following: moderate to severe mental health diagnosis (schizophrenic disorder, episodic mood disorder, delusional disorder, non-organic psychosis, anxiety, dissociative-somatoform disorder, personality disorder), end-stage renal disease, sickle cell disease
• Continuous enrollment in NPCCN for 10 of the previous 12 months

Sponsors & Collaborators

• Duke University: lead
• Northern Piedmont Carolina Community Care Partners: collaborator
• North Carolina Division of Medical Assistance: collaborator

Study Sites (1)

Duke University Medical Center (Division of Clinical Informatics)

Durham, North Carolina, 27710, United States

Location

MeSH Terms

Conditions

Asthma; Coronary Artery Disease; Diabetes Mellitus; Hypertension; Heart Failure

Condition Hierarchy (Ancestors)

Bronchial Diseases; Respiratory Tract Diseases; Lung Diseases, Obstructive; Lung Diseases; Respiratory Hypersensitivity; Hypersensitivity, Immediate; Hypersensitivity; Immune System Diseases; Coronary Disease; Myocardial Ischemia; Heart Diseases; Cardiovascular Diseases; Arteriosclerosis; Arterial Occlusive Diseases; Vascular Diseases; Glucose Metabolism Disorders; Metabolic Diseases; Nutritional and Metabolic Diseases; Endocrine System Diseases

Study Officials

• Eric Eisenstein, DBA

  Duke University

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: NON RANDOMIZED
• Masking: NONE
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: December 23, 2009
• First Posted: December 24, 2009
• Study Start: December 1, 2009
• Primary Completion: March 1, 2012
• Study Completion: September 1, 2012
• Last Updated: May 15, 2014

Record last verified: 2014-02

Locations

US (1)