A Randomised Control Trial of a Transitional Care Model in Singapore General Hospital

NCT02351648 | Completed

• 1 other identifier: 2012/848/E
• Study Type: interventional
• Target: 840
• Locations: 1 country
• Sites: 1

Brief Summary

To find out if a transitional care model can reduce the rate of unscheduled readmission to the Department of Internal Medicine (DIM) in SGH

Conditions

Chronic Diseases

Keywords

readmission; care transition

Outcome Measures

Primary Outcomes (1)

• Readmission rate

  A readmission episode is defined as an episode of readmission to any tertiary hospital within 30 days after index discharge from SGH Readmission rate is calculated by dividing the total number of admission by the total number of patients

  30 days after index discharge

Secondary Outcomes (5)

• Readmission rate

  up to 180 days after index discharge

• Quality of transitional care using a validated care transition measure (CTM-15) tool

  90 days after index discharge

• Emergency department attendance rate

  Up to 180 days after index discharge

• Time to first readmission

  Up to 90 days after index discharge

• Specialist Outpatient Clinic visits

  Up to 180 days after index discharge

Study Arms (2)

Intervention'

EXPERIMENTAL

Intervention extend from transfer of care to the study team from the initial admission medical team through 90 days after discharge Intervention in hospital includes the following. Comprehensive discharge planning based on the 6 principles. Discharge planning initially within 24 hours of recruitment Daily ward review of patients Weekly multi-disciplinary meeting Consolidation of medication and follow-up appointment before discharge Assessment of needs before discharge Comprehensive discharge summary and medication record at discharge Intervention after discharge: Work done mainly by integrated care nurse Review of patients within 48 hours after discharge via home visit or phone call Subsequent home visit as needed based on patient's needs At least weekly contact with pt or caregiver via telephone Telephone availability working weekday 8 AM to 5 PM Multi-disciplinary meeting for problematic cases Use chronic disease pathway for suitable patients

Other: a transitional care model

Control'

ACTIVE COMPARATOR

Patients receive usual standard of care from the internal medicine team

Other: Control

Interventions

a transitional care model OTHER

Intervention extend from transfer of care to the study team from the initial admission medical team through 90 days after discharge Intervention in hospital includes the following. Comprehensive discharge planning based on the 6 principles. Discharge planning initially within 24 hours of recruitment Daily ward review of patients Weekly multi-disciplinary meeting Consolidation of medication and follow-up appointment before discharge Assessment of needs before discharge Comprehensive discharge summary and medication record at discharge Intervention after discharge: Work done mainly by integrated care nurse Review of patients within 48 hours after discharge via home visit or phone call Subsequent home visit as needed based on patient's needs At least weekly contact with pt or caregiver via telephone Telephone availability working weekday 8 AM to 5 PM Multi-disciplinary meeting for problematic cases Use chronic disease pathway for suitable patients

Intervention'

Control OTHER

Patients receive usual standard of care from the internal medicine team

Control'

Eligibility Criteria

• Age: 21 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• More than 1 admission in the last 90 days

You may not qualify if:

• Subject is a non-resident
• Subject has no local home address
• Subject is from a long-term care facility during index admission
• Subject is unable to participate in telephone surveillance
• Subject is discharged before takeover
• Subject has impaired decision making capacity without surrogate decision maker
• Subject is pending or currently in critical care unit
• Subject or caregiver is mentally unstable
• Subject is haemodynamically unstable
• Subject requires acute inpatient respiratory support
• Subject requires acute inpatient dialysis support
• Subject pending surgical intervention
• Subject pending transfer to other specialist discipline
• Primary team consultant declined to participate in this research

Sponsors & Collaborators

• Singapore General Hospital: lead
• Agency for Integrated Care, Singapore: collaborator
• Duke-NUS Graduate Medical School: collaborator

Study Sites (1)

Singapore General Hospital

Singapore, Singapore, 169608, Singapore

Location

Related Publications (3)

• Coleman EA, Smith JD, Frank JC, Eilertsen TB, Thiare JN, Kramer AM. Development and testing of a measure designed to assess the quality of care transitions. Int J Integr Care. 2002;2:e02. doi: 10.5334/ijic.60. Epub 2002 Jun 1.

  PMID: 16896392 BACKGROUND

• Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003 Feb 4;138(3):161-7. doi: 10.7326/0003-4819-138-3-200302040-00007.

  PMID: 12558354 RESULT

• Mistiaen P, Poot E. Telephone follow-up, initiated by a hospital-based health professional, for postdischarge problems in patients discharged from hospital to home. Cochrane Database Syst Rev. 2006 Oct 18;2006(4):CD004510. doi: 10.1002/14651858.CD004510.pub3.

  PMID: 17054207 RESULT

MeSH Terms

Conditions

Chronic Disease

Condition Hierarchy (Ancestors)

Disease Attributes; Pathologic Processes; Pathological Conditions, Signs and Symptoms

Study Officials

• Kheng Hock Lee, MBBS

  Singapore General Hospital

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: SINGLE
• Who Masked: OUTCOMES ASSESSOR
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: January 21, 2015
• First Posted: January 30, 2015
• Study Start: October 1, 2012
• Primary Completion: December 1, 2014
• Study Completion: December 1, 2014
• Last Updated: January 30, 2015

Record last verified: 2015-01

Locations

SG (1)