Implementing an Emergency Department to Home Care Transition Intervention

NCT01973296 | Completed DMC

• 1 other identifier: 201200390
• Study Type: interventional
• Target: 62
• Locations: 1 country
• Sites: 2

Brief Summary

The purpose of this study is to determine whether a new way of educating/coaching chronically ill patients discharged from the Emergency Room will help them receive post-ER health care and strengthen their links to a regular, personal doctor.

Conditions

ED Patients With Chronic Medical Illnesses

Keywords

Health Literacy; Care Transition Intervention; Emergency Department Population; Access to Care

Outcome Measures

Primary Outcomes (1)

• Timely and appropriate outpatient medical follow-up

  The purpose of this aim is to determine if the ED to home care transition intervention improves patients' access to timely and appropriate outpatient medical follow-up. Patient response to telephone questionnaire will be used to determine time to physician follow-up and type of physician encounter.

  31-60 days after Emergency Department (ED) visit

Secondary Outcomes (1)

• Patient activation measure (PAM) level

  31-60 days following ED visit

Study Arms (2)

ED to home care transition

EXPERIMENTAL

The ED to home care transition intervention is a 4-week program that uses a Area Agency on Aging coach to conduct a home visit and three follow up phone calls to help patients develop the skills needed for self-management and to communicate with healthcare providers.

Behavioral: ED to home care transition

Usual Care

OTHER

Patients randomized to usual care will receive verbal and written discharge instructions from the treating emergency department physician and nurse as is the standard of care.

Other: Usual Care

Interventions

ED to home care transition BEHAVIORAL

The CTI coach's role is to build self-management capabilities for the patient and caregiver. During each contact, the coach reviews the four components of the CTI: 1: Follow-up Medical Visit. 2: Knowledge of Red Flag Symptoms. 3: Medication Reconciliation. 4: The Personal Health Record (PHR). The coach assists the patient use the PHR to document and maintain vital information and to communicate with providers.

Also known as: Care Transition Intervention (CTI)

ED to home care transition

Usual Care OTHER

Patients randomized to usual care will receive verbal and written discharge instructions from the treating emergency department physician and nurse as is the standard of care.

Usual Care

Eligibility Criteria

• Age: 60 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• years of age or older,
• are on Medicare,
• are community dwelling,
• reside within the geographical area defined by specific zip codes (to enable home visits),
• have a working telephone, and
• have at least one of the following conditions documented in their medical record: congestive heart failure, chronic obstructive pulmonary disease, coronary artery disease, diabetes, stroke, pneumonia, medical and surgical back conditions (predominantly spinal stenosis), hip fracture, peripheral vascular disease, cardiac arrhythmias, deep venous thrombosis, pulmonary embolism, peptic ulcer disease or hemorrhage.
• health literacy will be assessed with the 66-item Rapid Estimate of Adult Literacy in Medicine (REALM)(Davis, Crouch et al.)

You may not qualify if:

• current diagnosis of psychosis,
• active substance abuse related to alcohol or drugs,
• cancer,
• dialysis
• history of organ transplantation,
• have dementia without a live-in caregiver, or
• in hospice care,
• reside outside the defined geographical area,
• reside in a skilled nursing facility, or
• assisted living will be excluded

Sponsors & Collaborators

• University of Florida: lead
• Emergency Medicine Foundation: collaborator

Study Sites (2)

UF Health

Gainesville, Florida, 32608, United States

Location

UF Health

Jacksonville, Florida, 32209, United States

Location

Study Officials

• Donna L Carden, MD

  University of Florida

  PRINCIPAL INVESTIGATOR

Study Design

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

Study Record Dates

• First Submitted: October 15, 2013
• First Posted: October 31, 2013
• Study Start: November 1, 2013
• Primary Completion: December 1, 2014
• Study Completion: December 1, 2014
• Last Updated: January 26, 2015

Record last verified: 2015-01

Locations

US (2)