Study of the Impact of a Hospital Discharge Care Coordination Program in an Elderly Population

NCT01440907 | Completed

• 1 other identifier: C023699-22
• Study Type: interventional
• Target: 201
• Locations: 1 country
• Sites: 2

Brief Summary

The purpose of this research study is to evaluate the effect of a health information exchange (HIE)-supported care coordination package on 30-day readmission rates in a frail elderly population.

Conditions

Hospital Readmission

Keywords

Health Information Technology; Health Records, Personal; Hospital Information Systems; Patient Access to Records; Medical Records; Medical Record Systems, Computerized

Outcome Measures

Primary Outcomes (1)

• Hospital Readmission Rates Post 30-day Discharge

  To determine the impact of a health information exchange (HIE) care coordination program on reducing hospital readmissions rates post 30-day discharge from Maimonides Medical Center.

  1 year

Secondary Outcomes (1)

• Number of inpatient hospital days within 30 days of discharge

  1 year

Study Arms (2)

Intervention Group

EXPERIMENTAL

Those age 65 or older who are discharged from Maimonides Medical Center to home during the study period and enrolled in the Care Coordination Program

Other: Care Coordination Program

Control Group

NO INTERVENTION

Those age 65 or older who are discharged from Maimonides Medical Center to home

Interventions

Care Coordination Program OTHER

The Care Coordination Program includes: (1) access to a secure online personal health record (PHR) that people can logon and manage their health information, as well as receive alerts and reminders about action items for them to take on their healthcare; and (2) depending on the patient's health care needs, nursing support (either in-person or by phone).

Also known as: Safe at Home Project

Intervention Group

Eligibility Criteria

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

You may qualify if:

• Weill Cornell Investigators will be receiving a HIPAA-compliant de-identified dataset from the Brooklyn Health Information Exchange (BHIX) that includes:
• Demographic data information
• Diagnoses (admission, discharge, readmission)
• Whether the patient was readmitted readmission, # of inpatients days if the patients was readmitted
• Care coordination program statistics (e.g. usage of the personal health record, and frequency of contact with nursing support staff).
• The data set will include data of the following individuals:
• Intervention Dataset (Group 1): Those age 65 or older who are discharged from Maimonides to home during the study period and enrolled in the Care Coordination Program.
• Control Dataset (Group 2): Those age 65 or older who are discharged from Maimonides to home during the study period.

You may not qualify if:

• Transferred on the day of discharge to another acute care hospital, admitted to a hospital specialty unit, admitted to an inpatient rehabilitation facility, or admitted to a long-term care hospital;
• Approached and declined to participate in the Care Coordination Program.

Sponsors & Collaborators

• Weill Medical College of Cornell University: lead
• New York State Department of Health: collaborator
• Maimonides Medical Center: collaborator

Study Sites (2)

Maimonides Medical Center

Brooklyn, New York, 11219, United States

Location

Brooklyn Health Information Exchange (BHIX)

Brooklyn, New York, 11220, United States

Location

Related Publications (4)

• Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009 Apr 2;360(14):1418-28. doi: 10.1056/NEJMsa0803563.

  PMID: 19339721 BACKGROUND

• Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004 May;52(5):675-84. doi: 10.1111/j.1532-5415.2004.52202.x.

  PMID: 15086645 BACKGROUND

• Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006 Sep 25;166(17):1822-8. doi: 10.1001/archinte.166.17.1822.

  PMID: 17000937 BACKGROUND

• Peikes D, Chen A, Schore J, Brown R. Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. JAMA. 2009 Feb 11;301(6):603-18. doi: 10.1001/jama.2009.126.

  PMID: 19211468 BACKGROUND

Study Officials

• Jessica S Ancker, MPH, PhD

  Weill Medical College of Cornell University

  PRINCIPAL INVESTIGATOR

• Melissa C Miller, MPH

  Weill Medical College of Cornell University

  STUDY CHAIR

• Rainu Kaushal, MD, MPH

  Weill Medical College of Cornell University

  STUDY DIRECTOR

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: September 23, 2011
• First Posted: September 27, 2011
• Study Start: May 1, 2011
• Primary Completion: June 1, 2012
• Study Completion: July 1, 2013
• Last Updated: January 24, 2017

Record last verified: 2017-01

Data Sharing

• IPD Sharing: Will share

Locations

US (2)