Transition From Hospital to Home Post Cardiac Condition

NCT01431846 | Completed Results

• 1 other identifier: RRP 11-242
• Study Type: interventional
• Target: 19
• Locations: 1 country
• Sites: 1

Brief Summary

The study had three parts: Part 1: Patients (or their home caretakers) who live outside of Denver and receive their primary care at a location other than the Denver VAMC were interviewed after their discharge. The interview covered the patient's perspective about the transition of their medical care from the Denver VA to their primary care facility. Part 2: Primary care providers from the VA facilities that refer patients to the Denver VA were interviewed regarding their opinions of transition process from the Denver VA back to the primary care VA facilities. Part 3: The data from the above interviews were used to develop an intervention to improve the transition process from the Denver VA back to the primary care VA facilities.

Conditions

Cardiac Condition

Outcome Measures

Primary Outcomes (1)

• See Primary Outcome Description Below

  Follow up appointment within 2 weeks of discharge back to their primary care providers at a primary care facility from a tertiary referral center.

  Within 2 weeks of discharge

Study Arms (3)

Discharge Patient

NO INTERVENTION

Eight patients who were being discharged from Denver VA Medical Center for cardiac care to their primary care providers were recruited at the time of discharge and completed an interview two weeks following their discharge. Patients were asked to describe their transition to home and identify barriers and facilitators of this process, their understanding of their medical condition, new medications prescribed, timeliness of follow-up visit with their PCP and knowledge of signs/symptoms in which they should seek medical attention.

Providers

NO INTERVENTION

Three providers who refer patients to the Denver VA Medical Center for cardiac care were interviewed to identify barriers and facilitators from their perspective of following-up with patients after their hospitalization at Denver VAMC. Additionally, the same information was asked of providers who participated in two focus groups in the Grand Junction VA.

Intervention

EXPERIMENTAL

Informed by the interviews and best practices from the literature, pilot test the transitions of care intervention that targets patients and providers to evaluate the feasibility of the intervention to improve process of care measures, including: 1) PCP follow-up within 2-4 weeks of hospital discharge; 2) medications reconciled between pre and post-hospital discharge; 3) discharge summary available to PCP at time of visit; and 4) patient awareness of symptoms that require medical attention

Behavioral: Intervention

Interventions

Intervention BEHAVIORAL

Informed by the interviews and best practices from the literature, pilot test the transitions of care intervention that targets patients and providers to evaluate the feasibility of the intervention to improve process of care measures, including: 1) PCP follow-up within 2-4 weeks of hospital discharge; 2) medications reconciled between pre and post-hospital discharge; 3) discharge summary available to PCP at time of visit; and 4) patient awareness of symptoms that require medical attention

Intervention

Eligibility Criteria

• Age: 18 Years - 90 Years
• Sex: all
• Healthy Volunteers: Yes
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• Aims 1 and 3:
• Patients transferred from primary care VA facilities (i.e., Cheyenne, Grand Junction, Sheridan, Ft. Harrison) for cardiac care (e.g., heart failure, acute myocardial infarction) or procedures (coronary angiography, pacemaker implantation) to the Denver VAMC and discharged home to follow-up with their primary care provider, were eligible.
• Aim 2:
• Providers from VA primary care facilities, (i.e., Cheyenne, Grand Junction, Sheridan, and Ft. Harrison) who took care of patients discharged from the Denver VAMC for cardiology care, were eligible for the qualitative interviews.

You may not qualify if:

• Aims 1 and 3:
• Planned discharge to nursing home or skilled nursing facility;
• Irreversible, non-cardiac medical condition (e.g. metastatic cancer) likely to affect 6-month survival or ability to execute study protocol;
• Lack of telephone/ cell phone; and
• VA is not their primary source of care or their PCP is not in the VA system.

Sponsors & Collaborators

• US Department of Veterans Affairs: lead

Study Sites (1)

VA Eastern Colorado Health Care System, Denver, CO

Denver, Colorado, 80220, United States

Location

Related Publications (1)

• Hira RS, Kennedy K, Nambi V, Jneid H, Alam M, Basra SS, Ho PM, Deswal A, Ballantyne CM, Petersen LA, Virani SS. Frequency and practice-level variation in inappropriate aspirin use for the primary prevention of cardiovascular disease: insights from the National Cardiovascular Disease Registry's Practice Innovation and Clinical Excellence registry. J Am Coll Cardiol. 2015 Jan 20;65(2):111-21. doi: 10.1016/j.jacc.2014.10.035.

  PMID: 25593051 RESULT

MeSH Terms

Interventions

Methods

Intervention Hierarchy (Ancestors)

Investigative Techniques

Results Point of Contact

• Title: Dr. Michael Ho
• Organization: Eastern Colorado Health Care System

michael.ho@va.gov

720-857-5115

Study Officials

• Michael Ho, MD PhD

  VA Eastern Colorado Health Care System, Denver, CO

  PRINCIPAL INVESTIGATOR

Publication Agreements

• PI is Sponsor Employee: No
• Restrictive Agreement: No

Study Design

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

Study Record Dates

• First Submitted: June 23, 2011
• First Posted: September 12, 2011
• Study Start: August 1, 2011
• Primary Completion: December 1, 2012
• Study Completion: December 1, 2012
• Last Updated: April 28, 2015
• Results First Posted: February 10, 2015

Record last verified: 2014-09

Locations

US (1)