Intervening With and Improving Care for Patients at Risk for Frequent Hospital Admissions

NCT01292096 | Completed Phase 1

• 1 other identifier: 07-649
• Study Type: interventional
• Target: 19
• Locations: 1 country
• Sites: 1

Brief 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.

Conditions

Hospitalization; Patient Readmission

Keywords

homelessness; substance use; frequent hospitalization; frequent users of health services; enhanced care management; coordination services p; high risk for frequent hospitalization

Outcome Measures

Primary Outcomes (1)

• Housing placement

  Number of eligible chronically homeless patients placed in transitional or permanent housing

  1 year

Secondary Outcomes (2)

• Patient retention in program

  1 year

• Linkage to primary care provider

  1 year

Interventions

Provision of extra (care coordination and management) services OTHER

The pilot intervention begins 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.

Eligibility Criteria

• Age: 18 Years - 64 Years
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64)

You may qualify if:

• Patients identified at the time of a current hospital admission by a predictive algorithm (algorithmic risk score of 50 or greater) as being at high risk for hospital readmission in the following 12 months
• English or Spanish speaking
• Fee-for-service Medicaid or uninsured patients
• Ages 18-64

You may not qualify if:

• Neither English or Spanish-speaking,
• Institutionalized when not admitted to the hospital
• Unable to communicate
• HIV positive (because HIV positive patients have resources available to them from different and unrelated funding streams, and receive primary care at an off-site location)

Sponsors & Collaborators

• NYU Langone Health: lead
• United Hospital Fund: collaborator
• The New York Community Trust: collaborator

Study Sites (1)

Bellevue Hospital Center Department of Emergency Medicine, A345

New York, New York, 10016, United States

Location

Related Publications (1)

• Raven MC, Doran KM, Kostrowski S, Gillespie CC, Elbel BD. An intervention to improve care and reduce costs for high-risk patients with frequent hospital admissions: a pilot study. BMC Health Serv Res. 2011 Oct 13;11:270. doi: 10.1186/1472-6963-11-270.

  PMID: 21995329 DERIVED

MeSH Terms

Conditions

Substance-Related Disorders

Interventions

Therapeutics

Condition Hierarchy (Ancestors)

Chemically-Induced Disorders; Mental Disorders

Study Design

• Study Type: interventional
• Phase: phase 1
• Allocation: NA
• Masking: NONE
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: SINGLE GROUP
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: January 31, 2011
• First Posted: February 9, 2011
• Study Start: August 1, 2007
• Primary Completion: March 1, 2009
• Study Completion: March 1, 2009
• Last Updated: March 2, 2016

Record last verified: 2016-02

Locations

US (1)