Enhanced Discharge Planning Program -- Prospective

NCT01378234 | Completed

• 1 other identifier: 08121903-IRB02
• Study Type: interventional
• Target: 740
• Locations: 1 country
• Sites: 1

Brief Summary

The Enhanced Discharge Planning Program (EDPP) is an intervention designed to help older adults safely transition to the community after discharge. This is achieved through telephonic care coordination facilitated by social workers. EDPP social workers ensure full implementation of the discharge plan, assist with coordinating community resources and follow-up appointments, and intervene around other issues that may arise as a result of a complex transition. The EDPP intervention is currently being offered to some older adult patients discharged from Rush University Medical Center. Case managers refer older adult patients on selected units who they believe may be at risk for adverse events post-discharge. While this service is being provided to patients, it has not yet been formally evaluated. This randomized controlled trial will provide data necessary for a more rigorous evaluation of the efficacy of this intervention.

Conditions

Patient Admission; Patient Discharge

Outcome Measures

Primary Outcomes (4)

• Readmissions

  Readmission to hospital within 30 days after index discharge date

  30 days

• Readmissions

  Readmission to hospital within 60 days of index discharge date

  60 days

• Readmissions

  Readmission to hospital within 90 days of index discharge date

  90 days

• Readmissions

  Readmission to hospital within 180 days of index discharge date

  180 days

Secondary Outcomes (4)

• Stress

  30 days

• Physician follow-up

  30 days

• Mortality

  30 days

• Patient needs

  30 days

Study Arms (2)

EDPP Intervention

EXPERIMENTAL

Receive EDPP transitional care intervention from social worker upon hospital discharge

Behavioral: Enhanced Discharge Planning Program transitional care

Usual Care

NO INTERVENTION

Receive usual care upon hospital discharge

Interventions

Enhanced Discharge Planning Program transitional care BEHAVIORAL

Enhanced Discharge Planning Program (EDPP) provides telephonic short-term post-discharge social work services that assess and intervene from a biopsychosocial perspective for at-risk older adults returning home after an inpatient hospitalization. EDPP follows a four-step process to with three guiding tasks to reach the goal of preventing avoidable adverse events post-discharge: 1. Ensure patients understand the discharge plan of care and receive recommended services while screening for unidentified medical or social needs 2. Connect patients to outpatient health services (ex: home health, in-home services, dialysis, radiology, laboratory services, specialty care) with particular emphasis on the first physician follow-up appointment 3. Supporting caregivers to reduce stress and burden

Also known as: EDPP

EDPP Intervention

Eligibility Criteria

• Age: 65 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Older Adult (65+)

You may qualify if:

• Must meet all the following criteria:
• Aged 65+
• English speaking
• Returning home after discharge
• + medication prescribed
• Must also meet one additional criterion:
• Lives alone
• Without a source of emotional support
• Without a support system for care in place
• Discharged with a service referral
• High risk for falls
• Inpatient hospitalization within 12 months
• Identified in depth psychosocial need
• High risk medication prescribed

You may not qualify if:

• Primary diagnosis of transplant
• Non-English speaking
• Discharged to a facility

Sponsors & Collaborators

• Rush University Medical Center: lead

Study Sites (1)

Rush University Medical Center

Chicago, Illinois, 60612, United States

Location

MeSH Terms

Interventions

2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine

Study Officials

• Robyn Golden, LCSW

  Rush University Medical Center

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: NONE
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Associate Vice President

Study Record Dates

• First Submitted: June 17, 2011
• First Posted: June 22, 2011
• Study Start: June 1, 2009
• Primary Completion: July 1, 2010
• Study Completion: July 1, 2010
• Last Updated: September 8, 2023

Record last verified: 2023-09

Locations

US (1)