Achieving Patient-Centered Care and Optimized Health In Care Transitions by Evaluating the Value of Evidence

NCT02354482 | Completed Results

• 1 other identifier: 3048112229
• Study Type: observational
• Target: 7,939
• Locations: 1 country
• Sites: 1

Brief Summary

Funded by the Patient Centered Outcome Research Institute (PCORI), nationally recognized leaders in health care and research methods are partnering with patients and caregivers to evaluate the effectiveness of current efforts at improving care transitions and develop recommendations on best practices for patient-centered care transitions and guidance for spreading them across the U.S.

Conditions

Care Transitions

Outcome Measures

Primary Outcomes (2)

• Hospital Readmission

  Readmission to the hospital within 30 days of discharge.

  30 days post hospital discharge

• Emergency Department (ED) Visit

  Visit to the ED within 30 days of hospital discharge.

  30 days post hospital discharge

Study Arms (1)

Diverse, high-risk patient populations

Behavioral: Patient Communication and Care Management; Behavioral: Home-Based Trust, Plain Language, and Coordination; Behavioral: Hospital-Based Trust, Plain Language, and Coordination; Behavioral: Patient/Caregiver Assessment and Provider Information Exchange; Behavioral: Assessment and Teach Back; Other: Standard of Care (Reference)

Interventions

Patient Communication and Care Management BEHAVIORAL

Received the following Transitional Care strategies: 1. Helpful Health Care Contact OR Symptom Management 2. Post-discharge Care Consultation 3. Patient Goal/Preference Assessment 4. Plain Language Communication in Hospital 5. Plain Language Communication at Home 6. Transition Summary for Patients and Family Caregivers

Diverse, high-risk patient populations

Home-Based Trust, Plain Language, and Coordination BEHAVIORAL

Received the following Transitional Care Strategies: 1. Transition Team 2. Home visits 3. Plain Language Communication at Home 4. Promote Trust at Home 5. Referral to Community Services 6. Follow-up Appointment

Diverse, high-risk patient populations

Hospital-Based Trust, Plain Language, and Coordination BEHAVIORAL

Received the following Transitional Care Strategies: 1. Post-discharge care consultation 2. Identify High-Risk Patients and Intervene 3. Medication Reconciliation 4. Plain Language Communication in Hospital 5. Promote Trust in the Hospital 6. Transition Summary for Patients and Family Caregivers

Diverse, high-risk patient populations

Patient/Caregiver Assessment and Provider Information Exchange BEHAVIORAL

Received the following Transitional Care Strategies: 1. Patient Goal/Preference Assessment 2. Identify High-Risk Patients and Intervene 3. Timely Exchange of Critical Patient Information among Providers 4. Patient/Family Caregiver Transitional Care Needs Assessment

Diverse, high-risk patient populations

Assessment and Teach Back BEHAVIORAL

Received the following Transitional Care Strategies: 1. Post-discharge care consultation 2. Language Assessment 3. Teach Back for Information and Skills

Diverse, high-risk patient populations

Standard of Care (Reference) OTHER

No specific Transitional Care Strategy

Diverse, high-risk patient populations

Eligibility Criteria

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

Study Population

Project ACHIEVE will focus on Medicare fee-for-services beneficiaries and study diverse high risk patient populations, including those with: 1) multiple chronic conditions; 2) mental health issues; 3) rural area domicile; 4) limited English proficiency or low health literacy; 5) low socioeconomic status; 6) Medicare and Medicaid dual eligible; 7) disabled and younger than 65.

You may qualify if:

• diverse high risk patient populations, including those with:
• multiple chronic conditions
• mental health issues
• rural area domicile
• limited English proficiency or low health literacy
• low socioeconomic status
• Medicare and Medicaid dual eligible
• disabled and younger than 65.

You may not qualify if:

• children
• non-Medicare patients
• Under police custody
• Under suicide watch
• In-hospital death
• Transferred (not discharged) to another acute care hospital
• Discharged against medical advice
• Admission for primary diagnosis of psychiatric conditions
• Admission for rehabilitation
• Admission for medical treatment of cancer

Sponsors & Collaborators

• Mark Williams: lead
• University of Pennsylvania: collaborator
• Boston Medical Center: collaborator
• Westat: collaborator
• Kaiser Permanente: collaborator
• Telligen, Inc.: collaborator
• University of Illinois at Chicago: collaborator
• Hospital Research & Education Trust, American Hospital Association: collaborator
• Joint Commission Resources: collaborator
• America's Essential Hospitals: collaborator
• Louisiana State University Health Sciences Center Shreveport: collaborator
• United Hospital Fund: collaborator
• Caregiver Action Network: collaborator
• National Association of Area Agencies on Aging: collaborator

Study Sites (1)

UK Healthcare

Lexington, Kentucky, 40536, United States

Location

Related Publications (1)

• Li J, Brock J, Jack B, Mittman B, Naylor M, Sorra J, Mays G, Williams MV; Project ACHIEVE Team. Project ACHIEVE - using implementation research to guide the evaluation of transitional care effectiveness. BMC Health Serv Res. 2016 Feb 19;16:70. doi: 10.1186/s12913-016-1312-y.

  PMID: 26896024 DERIVED

MeSH Terms

Interventions

Restraint, Physical; Standard of Care

Intervention Hierarchy (Ancestors)

Behavior Control; Therapeutics; Immobilization; Investigative Techniques; Quality Indicators, Health Care; Quality of Health Care; Health Services Administration; Health Care Quality, Access, and Evaluation

Results Point of Contact

• Title: Jessica Clouser
• Organization: University of Kentucky

jess.clouser@uky.edu

8593230284

Study Officials

• Mark V Williams, MD

  University of Kentucky

  PRINCIPAL INVESTIGATOR

Publication Agreements

• PI is Sponsor Employee: Yes

Study Design

• Study Type: observational
• Observational Model: COHORT
• Time Perspective: PROSPECTIVE
• Sponsor Type: OTHER
• Responsible Party: SPONSOR INVESTIGATOR
• PI Title: Principal Investigator

Study Record Dates

• First Submitted: January 29, 2015
• First Posted: February 3, 2015
• Study Start: March 1, 2015
• Primary Completion: April 30, 2019
• Study Completion: June 30, 2019
• Last Updated: November 26, 2019
• Results First Posted: November 26, 2019

Record last verified: 2019-11

Data Sharing

• IPD Sharing: Will not share

Locations

US (1)