Impact of a Transitional Care Program on 30-Day Hospital Readmissions for Elderly Patients Discharged From a Short Stay Geriatric Ward

NCT02421133 | Completed

• 1 other identifier: 2014.874
• Study Type: interventional
• Target: 630
• Locations: 1 country
• Sites: 9

Brief Summary

In France, it has be estimated that the hospital readmission rate within 30 days of patients aged 75 or older is 14% (IC95% \[12.0-16.7\]), nearly a quarter being avoidable. There is evidence that interventions "bridging" the transition from hospital to home involving a dedicated professional (usually nurses) would be most effective in reducing the risk of readmission, but the level of evidence of current studies is low. Our study aims to assess the impact of a program of transitional care from hospital to home for people of 75 years old or more admitted to acute care.

Conditions

Geriatrics

Keywords

Care transition program; Patient readmission; Transition Nurse; Stepped wedge; elderly

Outcome Measures

Primary Outcomes (1)

• 30-Day unscheduled hospital readmission or emergency visit rate after the index hospital discharge.

  Unscheduled hospital readmissions are hospitalizations that are not planned at the moment of the discharge (for example: hospitalization after an emergency visit or upon request of the primary care physician).

  Within 30 days after hospital discharge.

Secondary Outcomes (10)

• Length of stay in the short stay geriatric ward (index hospitalization)

  Patients will be followed for the duration of hospital stay, an expected average between 2 days and 30 days

• Unscheduled hospital readmissions or emergency room visits

  Within 30 and 90 days after the index hospital discharge.

• Free-hospitalization survival

  Within 30 and 90 days after the index hospital discharge.

• Mortality rate

  Within 30 and 90 days after the index hospital discharge.

• Adverse events (i.e. falls)

  Within 30 days after the index hospital discharge.

Study Arms (2)

Transitional care program.

EXPERIMENTAL

The transitional care program from hospital to home will be implemented at three steps: during the patient's stay in hospital, the day of the discharge and during 4 weeks after discharge.

Other: Transitional care program.

standard care program

OTHER

No intervention liable to affect the care provided to the patients, the organization of care or the practices of health care professionals will be implemented during the control period (time steps without intervention).

Other: standard care program

Interventions

standard care program OTHER

The patients will be discharged according to the usual care plan of each participating hospital. The medical team does a medical and geriatric assessment of the patients according to the recommendations. The communication of information to the primary care providers (nurse, primary care physician…) is left to the discretion of the medical teams of the discharging hospitals, according to their habits of work.

standard care program

Transitional care program. OTHER

During the patient's stay in hospital, the transition nurse creates a transitional care file including information about the patient (inpatient medical and nurse care plan, medications), the discharge plan, and the contact information of the relevant primary care providers. She notifies the patient's primary care physician of the date of the discharge to home, of the potential medical problems and of the discharge care plan; a primary care physician visit is planned the month following the discharge. The day of the hospital discharge: meeting with the patient to review the follow-up recommendations. The transition nurse verifies that the medications are prescribed accordingly with the discharge plan, that the patient and his caregiver understand the prescription and are informed with the planned appointments and the biological monitoring. During 4 weeks after the hospital discharge: follow-up by the transition nurse once a week, alternately by telephone and home visit.

Transitional care program.

Eligibility Criteria

• Age: 75 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Older Adult (65+)

You may qualify if:

• Patient hospitalized for 48 hours or more in one of the acute geriatric service participating to the study.
• Aged 75 or older.
• Leaving at home and with home as the planned discharge after the admission.
• At risk of hospital readmission emergency visit rates after discharge (if he has two or more of the following criteria (taken from the Triage Risk Screening Tool and from the 2013 French recommendation)).

You may not qualify if:

• Patient leaving in a retirement home.
• Patient hospitalized at home.
• Patient leaving at home but at 30 km (18 miles) or more from the service of his index admission

Sponsors & Collaborators

• Hospices Civils de Lyon: lead

Study Sites (9)

CH Gériatrique des Monts d'Or

Albigny-sur-Saône, 69250, France

Location

CH Bourg-en-Bresse

Bourg-en-Bresse, 01012, France

Location

Centre Hospitalier Alpes Léman

Contamine-sur-Arve, 74130, France

Location

Hôpital Édouard Herriot

Lyon, 69437, France

Location

Centre Hospitalier Lyon Sud

Pierre-Bénite, 69495, France

Location

CHG Annecy

Pringy, 74374, France

Location

CH Saint-Chamond

Saint-Chamond, 42400, France

Location

Clinique des portes du sud

Vénissieux, 69200, France

Location

CH Villefranche

Villefranche, 69655, France

Location

Related Publications (1)

• Occelli P, Touzet S, Rabilloud M, Ganne C, Poupon Bourdy S, Galamand B, Debray M, Dartiguepeyrou A, Chuzeville M, Comte B, Turkie B, Tardy M, Luiggi JS, Jacquet-Francillon T, Gilbert T, Bonnefoy M. Impact of a transition nurse program on the prevention of thirty-day hospital readmissions of elderly patients discharged from short-stay units: study protocol of the PROUST stepped-wedge cluster randomised trial. BMC Geriatr. 2016 Mar 3;16:57. doi: 10.1186/s12877-016-0233-2.

  PMID: 26940678 RESULT

Study Officials

• Marc Bonnefoy

  Centre Hospitalier Lyon Sud-Hospices Civils de Lyon

  PRINCIPAL INVESTIGATOR

Study Design

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

Study Record Dates

• First Submitted: March 9, 2015
• First Posted: April 20, 2015
• Study Start: July 1, 2015
• Primary Completion: November 30, 2016
• Study Completion: November 30, 2016
• Last Updated: December 19, 2025

Record last verified: 2025-12

Locations

FR (9)