Improving Hospital-to-Home Care Transitions for High-risk Younger Adult Patients

NCT02532296 | Completed

• 1 other identifier: CHA-3222
• Study Type: interventional
• Target: 201
• Locations: 1 country
• Sites: 1

Brief Summary

Improving hospital-to-home care transitions can produce improvements in patient safety and health care outcomes, while decreasing medical costs. Most transitions research has examined strategies for older patients. This project, however, focuses on younger, high-risk patients within a safety net system. The proposed intervention is based on research that patient activation, as measured by the Patient Activation Measure (PAM), is correlated with risk for hospital readmission. The intervention seeks to increase PAM scores by employing a Transition Coach to coach patients, prior to and for 30-days after discharge, to (1) improve self-management skills through goal setting and goal attainment; (2) to enhance patient capacity to engage in trusting relationships with the Primary Care Provider (PCP), other medical specialists, family members of friends, and the Transition Coach; and (3) to improve ability to navigate the medical system. The investigators will conduct a randomized trial to determine; (a) if PAM scores can be increased in the 30-day after hospital discharge; (b) if increased PAM scores, in this setting, are correlated with changes in healthcare utilization patterns; and (c) if the intervention presents a viable strategy to change healthcare utilization patterns and reduce rehospitalizations.

Conditions

Patient Discharge

Outcome Measures

Primary Outcomes (1)

• Change from Baseline - Patient Activation Measure (PAM) and Utilization

  Comparison between pre-discharge PAM and 30-day post-discharge PAM. Hospital and ED visit and outpatient visits with PCP and Specialists at 7,14,30,60,90 days.

  7,14, 30, 60, 90 days post-discharge

Secondary Outcomes (6)

• Goal Setting and Achievement

  Hospital visit and 30 days post-discharge

• Relationship with Transition Coach (TC)

  Hospital visit and 30 days post-discharge

• Relationship with PCP

  30 days post-discharge

• Relationship with other medical providers

  30 days post-discharge

• Relationship with Home Support

  30 days post-discharge

Other Outcomes (1)

• Pre-intervention utilization

  1 year pre-hospitalization

Study Arms (2)

Control

ACTIVE COMPARATOR

Receive usual hospital discharge, care transition and post-discharge care.

Behavioral: Control

Transition Coach Intervention

EXPERIMENTAL

In addition to usual care, the intervention group receives care from a trained Transition Coach to support patients for 30 days after discharge.

Behavioral: Transition Coach (TC)

Interventions

Transition Coach (TC) BEHAVIORAL

TC reviews patient's medical record to understand current admission and the medical/psycho-social history. TC makes introductory hospital visit(s) with patient to establish rapport and to define post-discharge needs. Starting in-house and continuing after discharge, TC helps patient set transition goals to maximize healthcare outcomes. Post-discharge, TC offers a voluntary face-to-face visit with patient along with weekly outreach calls, which are designed to assist patient with goal setting and attainment, medical system navigation; medication management; medical follow-up; transportation; use of community resources; and self-care. Intervention lasts 30 days post-discharge; afterwards TC seeks to handoff to an outpatient care team member, to ensure continuity of care.

Transition Coach Intervention

Control BEHAVIORAL

Receives usual hospital-based care, discharge preparation, transitional care and outpatient care.

Control

Eligibility Criteria

• Age: 18 Years - 60 Years
• Sex: all
• Healthy Volunteers: Yes
• Age Groups: Adult (18-64)

You may qualify if:

• Age 60 or less
• PCP within CHA network
• Have had at least one previous hospitalization or two or more Emergency Department visit within CHA in the past year
• Hospitalized at Cambridge Hospital on Medicine or Surgery Service
• Discharged from Medicine or Surgery service to home

You may not qualify if:

• Age \> 60;
• Non-CHA PCP
• Discharged to rehabilitation or transferred to an outside hospital or to Psychiatry service

Sponsors & Collaborators

• Cambridge Health Alliance: lead

Study Sites (1)

Cambridge Hospital

Cambridge, Massachusetts, 02139, United States

Location

Study Officials

• Richard B Balaban, MD

  Cambridge Health Alliance

  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: July 17, 2015
• First Posted: August 25, 2015
• Study Start: June 1, 2015
• Primary Completion: July 1, 2016
• Study Completion: July 1, 2016
• Last Updated: August 5, 2016

Record last verified: 2016-08

Locations

US (1)