Relative Patient Benefits of a Hospital-PCMH Collaboration Within an ACO to Improve Care Transitions

NCT02130570 | Completed Results

• 1 other identifier: 2012P000096
• Study Type: interventional
• Target: 1,679
• Locations: 1 country
• Sites: 2

Brief Summary

The objective of this study is to design and implement a set of procedures (the intervention) to improve patients' experiences when they are discharged home from the hospital. Second, this study aims to look at how the intervention affects problems that are known to occur after discharge, including medication issues, worsening medical problems, or readmission to the hospital. The investigators will study how well patients recover the ability to do the things they could before they were admitted to the hospital and their opinions of the discharge process. Lastly, this study will look to understand the best way to implement the intervention into different hospitals and practices, and which types of patients benefit from it most.

Conditions

Adverse Events; Readmissions; Patient Engagement

Keywords

Adverse events; Readmissions; Patient Centered Medical Home (PCMH); Accountable Care Organizations (ACO); Medication reconciliation; Discharge Advocate; Patient engagement; Transitions of care; Transitions coach; Pharmacist intervention

Outcome Measures

Primary Outcomes (1)

• Proportion of Participants With an Adverse Event Within 30 Days After Index Discharge Date

  Proportion of Participants With an Adverse Event Within 30 Days after Index Discharge Date

  30 days after discharge

Secondary Outcomes (5)

• Proportion of Participants With New or Worsening Signs/Symptoms Within 30 Days of Discharge

  30 days after discharge

• Number of Patients With a Nonelective Readmission Within 30 Days of the Index Discharge Date

  30 days after discharge

• Change in Functional Status on the Modified Medical Outcomes Survey Short Form-12 (SF-12v2) From One Month Prior to Admission to 30 Days After Discharge.

  One month prior to admission to 30 days after discharge.

• Proportion of Participants With Positive Responses Regarding Patient Engagement and Opinions of the Discharge Process

  30 days after discharge

• Post-Discharge Health Care Utilization

  30 days after discharge

Study Arms (2)

Multi-Model Intensive Discharge Program

EXPERIMENTAL

Multi-Model Intensive Discharge Program

Other: Multi-Model Intensive Discharge Intervention

Usual Care

NO INTERVENTION

Usual Care

Interventions

Multi-Model Intensive Discharge Intervention OTHER

1. Inpatient medication safety interventions 2. Inpatient "discharge advocate" 3. Structured visiting nurse (VNA) appointments 4. Post-discharge phone call by primary care personnel within 2 business days of discharge 5. Structured post-discharge clinic appointment with PCP and other PCMH personnel within 2 weeks of discharge 6. Improved communication between inpatient and primary care teams 7. High-risk patients will receive additional interventions as needed: 1. Home pharmacist visit 2. Enrollment in the Partners integrated Care Management Program (iCMP) 3. Enrollment in telemedicine programs for patients with CHF 4. Palliative care consultation regarding goals of care 8. Novel health information technology to facilitate communication and transfer of clinical information

Multi-Model Intensive Discharge Program

Eligibility Criteria

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

You may qualify if:

• Potential subjects will be adult patients admitted to medical and surgical services at BWH and MGH, likely to be discharged back to the community, and whose PCP belongs to one of the Partners Community Healthcare, Inc. (PCHI) primary care practices that has met "Primed" criteria for being a PCMH, admits at least 2 patients to BWH or MGH, and has agreed to participate. Primed criteria are a standard set of requirements that cover 6 essential building blocks of PCMH practices: electronic health record, patient portal, team-based care, practice redesign, care management, and identification of high-risk patients. We estimate that of the approximately 300 PCHI adult primary care practices, 150 of them will meet PCMH criteria during the study and that 20 of them will qualify and be willing to participate in the study. We estimate that 12,000 such patients will be admitted to BWH and MGH over the 18-month study period, of which we will enroll 1700 patients. These patients are broadly representative of hospitalized patients and include several vulnerable populations, including the elderly (33% 65 or older), patients with multiple chronic conditions (47% with Elixhauser comorbidity score 5 or more), and racial and ethnic minorities (14% African American, 13% Latino).

You may not qualify if:

• Likely discharge to a location other than home (or to a caregiver's home)
• Police custody
• No telephone or homeless
• Previous enrolment in the study
• Patient unable to communicate in either English or Spanish

Sponsors & Collaborators

• Brigham and Women's Hospital: lead
• Patient-Centered Outcomes Research Institute: collaborator
• Massachusetts General Hospital: collaborator

Study Sites (2)

Massachusetts General Hospital

Boston, Massachusetts, 02114, United States

Location

Brigham and Women's Hospital

Boston, Massachusetts, 02115, United States

Location

MeSH Terms

Conditions

Patient Participation

Condition Hierarchy (Ancestors)

Patient Acceptance of Health Care; Treatment Adherence and Compliance; Health Behavior; Behavior

Results Point of Contact

• Title: Dr. Jeffrey L Schnipper, MD, MPH, FHM
• Organization: Brigham and Women's Hospital

jschnipper@partners.org

617-732-7063

Study Officials

• Jeffrey L Schnipper, MD, MPH

  Brigham and Women's Hospital

  PRINCIPAL INVESTIGATOR

Publication Agreements

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

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: SINGLE
• Who Masked: OUTCOMES ASSESSOR
• Purpose: OTHER
• Intervention Model: SEQUENTIAL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Associate Professor of Medicine

Model Details: This is a stepped-wedge design, where each primary care practice starts in usual care, and then at a randomly selected point in time switches to the intervention arm.

Study Record Dates

• First Submitted: May 1, 2014
• First Posted: May 5, 2014
• Study Start: June 1, 2013
• Primary Completion: November 1, 2015
• Study Completion: November 1, 2015
• Last Updated: August 20, 2019
• Results First Posted: August 20, 2019

Record last verified: 2019-08

Data Sharing

• IPD Sharing: Will share

Locations

US (2)